alifornia 
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[OSTEOPATHI C  MECHANICS 

A  TEXT-BOOK 


BY 


EDYTHE  F.  ASHMORE,  D.  0. 

DETROIT 

Formerly  Professor  of  Osteopathic  Technique, 
American  School  of  Osteopathy,  Kirksville,  Missouri 


WITH  82  ILLUSTRATIONS 
3  COLORED  PLATES 


JOURNAL  PRINTING  CO. 

KIRKSVILLE,  MISSOURI 
1915 


A 


COPYRIGHT.  1915,  BY  EDYTHE  ASHMORE 


PRINTED  IN   AMERICA 
JOURNAL  PRINTING    COMPANY 

K  I  HK-v  i  i.i.i:.  MISSOURI 


TO  MY  MOTHER 

EMMA  MAGINNIS  ASHMORE 

WHOSE   CONSTANT  ENCOURAGEMENT  HAS  INSPIRED  ME  TO  THE 
COMPLETION  OP  THIS  WORK 


OSTEOPATHIC  MECHANICS 


TABLE  OF  CONTENTS 

Chapter  Page 

I.  THE  LESION  . .  9 

II.  THE  NORMAL  MOVEMENTS  OF  THE  SPINE 20 

III.  LATERAL  CURVATURE  OF  THE  SPINE 30 

r\ 

IV.  FLEXION  AND  EXTENSION  LESIONS 65 

V.  ROTATION  AND  SIDEBENDING  LESIONS 87 

VI.  CERVICAL  LESIONS Ill 

VII.  SACRO-!LIAC  LESIONS 126 

VIII.  RIB  LESIONS 161 

IX.  OCCIPITO-ATLANTAL  LESIONS 187 

X.  CLAVICULAR  AND  OTHER  LESIONS 211 

XI.  SOFT  TISSUE  TECHNIQUE .222 

INDEX.  ..231 


OSTEOPATHIC  MECHANICS 


ERRATA 

Page  46,  line  22,  the  words  "lie  pon"  should  read  "lie  upon. " 

Page  87,  under  fig.  35,  "the  dottled  lines"  should  read  "the 
curved  lines. " 

Page  88,  footnote  2,  line  2,  the  word  "right"  should  be  in- 
serted between  "thus,  a  "  and  "rotation  lesion." 

Page  97,  "Experimental  palpation,  E"  should  read  "E2." 

Page  104,  line  12,  the  word  "left"  should  replace  the  word 
"right." 

Page  115,,  "Experimental  palpation,  G"  should  read  "G2". 

Page  121,  the  footnotes  should  be  numbered  "2"  and  "3" 
to  correspond  with  the  exponent  numbers  above. 

Page  197,  line  four,  "outward  flexion  movement"  should 
read ' '  outward  extension  movement. " 

Page  199,  line  16,  should  read  "and  the  normal  erect  posi- 
tion "etc. 


OSTEOPATHIC  MECHANICS 


PREFACE 

When  Dr.  Andrew  Taylor  Still  gave  to  the  world  the  philos- 
ophy of  Osteopathy  in  the  establishment  of  a  college  for  its  teach- 
ing, the  science  of  Osteopathy  was  yet  in  its  infancy,  for  like  many 
of  the  great  sciences,  it  began  as  an  art  in  the  brain  of  a  master. 
Thus  it  is  that  genius  gives  to  the  world  that  which  afterward  re- 
quires years  of  careful  research  and  study  to  confine  within  the 
regulations  of  principle  and  law.  It  is  not  strange,  therefore,  that 
in  the  third  decade  of  the  existence  of  the  parent  college  the  first 
textbook  of  the  mechanics  of  osteopathy  should  appear. 

The  scope  of  this  book  is  strictly  that  of  a  text-book  and  does 
not  aim  to  be  an  exhaustive  treatise  upon  the  subject  but  rather  a 
perspective  placing  before  the  mind  of  the  student  clearly  and 
briefly  certain  definite  facts  with  their  relative  values  to  the  end 
that  he  by  further  study  may  more  easily  attain  skill  in  osteo- 
pathic  diagnosis  and  practice. 

There  has  been  no  attempt  made  at  literary  brilliancy  nor 
startling  originality.  I  have  kept  in  mind  constantly  the  needs 
of  the  student  as  I  have  found  them  in  my  own  college  days  of 
fifteen  years  ago  and  during  the  past  year  while  teaching  the  Junior 
classes  of  the  American  School  of  Osteopathy.  Other  writers  in 
our  scientific  journals  have  covered  well  the  problems  of  technique 
and  to  them  I  am  much  indebted,  especially  to  Drs.  Carl  P.  Mc- 
Connell  and  Harry  Willis  Forbes. 

The  plan  of  presentation  in  this  book  is  distinctly  my  own 
for  no  other  teacher  to  my  knowledge  has  begun  the  subject  of 
osteopathic  mechanics  with  the  study  of  spinal  curvature.  From 
observation  I  do  not  hesitate  to  claim  that  it  has  decided  merits 
and  in  this  connection  I  wish  to  acknowledge  my  indebtedness  to 
Robert  W.  Lovett  of  Boston  whose  work  "Lateral  Spinal  Curva- 
ture," has  enlarged  my  understanding  of  the  movements  of  the 
spine  and  in  a  way  made  possible  much  of  the  development  of  the 
subject  of  spinal  subluxations. 

In  the  matter  of  terminology,  the  larger  part  of  this  book  was 
written  before  the  adoption  by  the  American  Osteopathic  Associa- 


8  OSTEOPATHIC  MECHANICS 

tion  of  the  nomenclature  and  definitions  prepared  by  a  committee 
of  the  heads  of  the  department  of  osteopathic  mechanics  in  the 
several  colleges.  Wherever  possible  I  have  given  both  old  and 
new  terms. 

In  the  matter  of  corrective  movements,  I  have  endeavored 
to  select  the  very  simplest,  those  illustrating  the  principles  of  cor- 
rection most  plainly.  The  height  of  the  practitioner,  his  weight, 
and  physical  strength  are  factors  that  induce  him  to  modify  the 
leverages  he  uses  in  operating  osteopathically  upon  patients  who 
show  as  many  variations  from  the  average  type  as  may  the  physi- 
cian himself. 

To  my  students  who  have  helped  in  the  construction  of  the 
illustrations  of  this  work  I  am  very  grateful  and  I  wish  to  express 
here  my  thanks  to  Drs.  Frances  Graves  and  Anna  E.  Northup, 
graduate  osteopaths,  to  Drs.  Clifford  L.  Baker,  Oliver  C. Foreman, 
and  E.  P.  Malone  of  the  class  of  January,  1916,  to  Miss  Beatrice 
L.  Jemmette  and  Mr.  L.  P.  Riemer  of  the  class  of  June,  1916,  and 
to  Mr.  Eugene  D.  Platt,  photographer,  of  the  January,  1917,  class. 

I  desire  to  express  my  thanks,  also,  to  the  editors  of  the 
Journal  of  Osteopathy  for  permission  to  use  illustrations  that 
have  appeared  in  their  pages  and  to  Dr.  Frank  P.  Millard  of 
Toronto  for  his  kindness  in  lending  me  the  zinc  etchings  of  the 
illustrations  drawn  by  himself. 

To  the  Founder  of  Osteopathy,  to  whom  each  osteopath  owes 
all  honor  and  appreciation,  I  wish  to  acknowledge  the  greatest 
debt  of  all  for  the  wonderful  system  of  healing  which  has  brought 
to  me  and  to  all  others  who  have  been  privileged  to  employ  it, 
the  happiness  that  comes  to  him  or  to  her  who  is  conscious  of 
having  helped  to  alleviate  the  suffering  of  humanity. 

EDYTHE  F.  ASHMORE,  D.  O. 
Kirksville,  Mo.,  July  25,  1915. 


OSTEOPATHIC  MECHANICS 


CHAPTER  I. 
THE  LESION 

OSTEOPATHIC  MECHANICS  is  a  system  of  animal  mechanics 
which,  taking  into  consideration  the  anatomical  parts  of  the 
human  body,  especially  the  bones,  ligaments,  and  muscles, 
recognizes  disturbances  in  their  relations,  in  particular  mal- 
alinements  and  subluxations  of  joints,  and  explains  the  prin- 
ciples by  which  may  be  secured  the  normal  apposition  and  adjust- 
ment of  part  with  part.  It  is  embraced  by  the  larger  subject  of 
the  PRINCIPLES  OF  OSTEOPATHY,  which  based  upon  the  sciences  of 
anatomy,  chemistry,  and  physiology,  by  the  application  of  a 
distinctive,  etiologic,  fundamental  truth,  establishes  an  exact 
diagnosis,  a  clear  pathology,  and  a  rational  system  of  therapy. 

The  central  thought  of  the  science  of  Osteopathy  is  the  lesion, 
which  has  been  defined  as  any  structural  perversion  which  pro- 
duces or  maintains  functional  disturbance.  The  word  lesion  has 
been  derived  from  the  Latin  verb,  laedere,  to  injure.  A  lesion, 
then,  is  any  maladjustment  which  ultimately  causes  an  injury  to 
tissues,  or  it  is  an  etiological  factor  in  the  production  of  disease 
and  manifests  pathological  effects.  A  lesion  is  itself  the  result 
of  injury  and  as  such  presents  certain  signs  and  symptoms.  With 
the  production  of  lesions,  with  their  signs  and  symptoms,  with 
their  removal,  are  Osteopathic  Mechanics  concerned.  The 
effects  of  lesion  are  covered  by  the  subjects  of  Osteopathic  Path- 
ology and  Practice. 

The  term  lesion  has  been  used  in  a  restricted  sense  to  mean 
any  anatomical  irregularity  of  a  joint  abnormal  to  the  individual 
and  the  result  of  injury  originating  without  the  joint  and  intrinsic 
or  extrinsic  to  the  organism  itself.  The  lesions  which  produce 

the  most  serious  effects  are  those  of  the  spinal  articulations,  the 

2 


10  OSTEOPATHIC  MECHANICS 

occiput  with  the  atlas,  the  sacrum  with  the  fifth  lumbar,  and  the 
innominates  (ossa  coxae)  with  the  sacrum,  for  the  reason  that 
these  joints  are  more  intimately  connected  with  the  two  nervous 
systems,  the  cranio-spinal  and  the  sympathetic.  Joint  lesions 
have  been  called  osseous  lesions,  for  of  first  consideration  in  a 
joint  are  the  articulating  surfaces. 

Lesions  are  the  result  of  injury,  direct  or  indirect:  direct 
when  acted  upon  by  forces  at  variance  with  the  usual  function 
of  the  joint;  indirect,  when  by  disturbance  in  the  function  of  the 
tissues  which  maintain  the  joint  in  balance,  lost  equilibrium  results. 
These  indirect  causes  have  been  termed  muscular  and  ligamentous 
lesions  and  should  not  be  confused  with  the  effects  manifest  in 
tissues  about  the  joint  secondary  to  osseous  maladjustment. 

A  muscular  lesion  is  a  contraction  or  contracture  and  is  the 
result  of  direct  violence  to  the  muscle  tissue  itself  or  is  caused 
indirectly  by  disturbance  in  the  nervous  mechanism  controlling 
the  action  of  the  muscle,  from 

1.  Irritative  influences. 

a.  Atmospheric  changes,  heat,  cold,  etc. 

b.  Vaso-motor  spasm. 

c.  Reflexes  from  viscera. 

d.  Toxins  in  the  blood  stream. 

e.  Fatigue. 

2.  Postural  defects. 

a.  Kyphosis. 

b.  Lordosis. 

c.  Lateral  curvature. 

3.  Pathological  changes  in  nerve  cells  or  neurons. 

A  strong  contraction  or  contracture  of  a  muscle  brings  its 
origin  and  insertion  closer  together  and  thus  may  be  the  first 
cause  of  a  vertebral  osseous  lesion. 

A  ligamentous  lesion  is  one  in  which  there  is  a  changed  condi- 
tion of  one  or  more  of  the  ligaments  of  the  joint;  it  may  be  described 
as  a  thickening  or  thinning  of  the  fibrous  tissue;  it  is  usually  the 
result  of  congestion  or  inflammation  and  its  effects  are  increased 
resistance  or  debility  in  the  joint.  Secondarily  to  ligamentous 
lesions  are  found  impaction  or  relaxation  osseous  lesions. 

An  impaction  lesion  of  a  vertebral  articulation  is  a  lesion 
which  is  characterized  by  an  approximation  of  all  the  bony  parts, 


OSTEOPATHIC  MECHANICS  11 

with  a  thinning  of  the  intervertebral  disc  and  a  thickening  of  the 
ligaments  about  the  joint. 

A  relaxation  lesion  of  a  vertebral  articulation  is  a  lesion  which 
is  characterized  by  hypermobility,  great  elasticity  of  the  inter- 
articular  fibrocartilage,  and  a  thinning  of  the  ligaments  about  the 
joint. 

Spinal  lesions  are  named  according  to  the  upper  of  the  two 
vertebrae  entering  into  lesion.  A  third  thoracic  lesion  means  a 
maladjustment  of  the  third-fourth  thoracic  articulation.  Lesions 
in  other  than  spinal  joints  are  named  from  the  distal  of  the  two 
bones  entering  into  the  joint;  thus,  a  subluxation  of  either  of  the 
sacroiliac  articulations  would  be  spoken  of  as  an  innominate 
lesion,  because  of  the  two  bones  entering  into  the  joint  the  ilium 
is  the  distal  bone. 

Osseous  lesions  are  of  two  kinds :  subluxations  and  traumatic 
lesions. 

A  SUBLUXATION  is  an  immobilization  of  a  joint  in  a  position 
of  normal  motion,  usually  at  the  extremity  of  a  given  movement. 
Subluxations  vary  as  individuals  vary.  One  man  may  have  an 
extremely  flexible  spine.  In  his  case  a  strain  would  immobilize 
a  certain  articulation  in  a  position  of  maximum  play  of  the  articular 
facets  one  upon  the  other.  Another  man  whose  spine  was  lacking 
in  flexibility,  a  condition  not  always  pathological  but  rather  due 
to  environment,  occupation,  hereditary  tendency,  would  from  the 
same  amount  of  strain  present  a  subluxation  wherein  the  articu- 
lating surfaces  were  immobilized  with  fully  one-half  of  their  faces 
in  apposition.  In  short,  lesion  means  immobilization  and  there 
can  be  no  mathematically  exact  limit  placed  upon  the  changes 
that  will  be  found  in  any  joint  the  result  of  a  given  offensive  force. 

A  TRAUMATIC  LESION  is  one  in  which  the  articulating  surfaces 
of  the  joint  are  immobilized  in  a  position  physiologically  abnormal 
to  the  joint  and  is  always  the  result  of  force  applied  in  a  direction 
ordinarily  impossible  to  the  planes  and  axes  of  the  joint.  There 
are  usually  two  kinds  of  traumatic  lesions: 

1.  Rotation  traumatic  lesions,  occurring  in  the 

a.  Lumbar  area,  produced  by  forced  rotation  with  the 

patient  in  the  flexed  or  erect  position. 

b.  Lower  thoracic  area,  produced  by  forced  rotation 

with  the  patient  in  the  position  of  flexion. 


12  OSTEOPATHIC  MECHANICS 

2.  Sidebending  traumatic  lesions,  occurring  in  the  thoracic 
area  above  the  eighth  thoracic  vertebra,  produced  by  forced  side- 
bending  with  the  patient  in  the  erect  or  hyperextended  position. 

Osseous  lesions  are  acute  or  chronic  according  to  whether 
or  not  they  are  of  recent  production,  or  whether  or  not  there  has 
been  a  pathological  defensive  reaction  in  the  surrounding  tissues. 
In  acute  lesions  the  effects  are  those  which  immediately  follow 
injury  and  hence  are  inflammatory  in  character. 

Chronic  lesions  are  those  which  have  been  structuralized  by 
adaptive  changes  in  the  soft  tissues  of  the  joint.  To  the  research 
work  of  a  number  of  osteopathists,  notably  among  whom  may  be 
mentioned  Drs.  Carl  P.  McConnell  and  Frank  Farmer,  are  we 
indebted  for  the  knowledge  of  the  conditions  extant  in  osseous 
spinal  lesions  of  the  chronic  type.  The  structural  changes  present 
are  in  direct  ratio  to  the  extent  of  the  lesion  for  in  the  severe  type 
there  may  be  present  ossification  of  parts  of  those  ligaments  which 
contain  yellow  elastic  fibrous  tissue.  In  the  minor  gradations, 
the  following  effects  of  lesions  are  characteristic:  the  muscle 
fasciculi  about  the  joint  undergo  a  myositis;  the  nerves  to  contract- 
ured  muscles  degenerate;  after  the  muscles  are  dissected  away 
from  the  joint,  there  still  remains  restricted  articular  motion; 
there  is  present  much  thickening  of  the  ligaments  on  the  side  toward 
which  the  vertebra  is  rotated  or  flexed;  the  intervertebral  discs 
show  compression  changes;  the  articular  surfaces  are  not  path- 
ologically involved,  synovial  fluid  is  present,  and  there  are  no 
adhesions.  It  is  unquestionably  the  damage  done  to  the  ligaments 
that  maintains  the  osseous  lesion. 

THE  SPINAL  JOINT 

Briefly,  in  the  light  of  the  mechanical  problems  it  presents, 
it  is  best  to  review  the  vertebral  articulation,  anatomically  and 
physiologically. 

The  spinal  column  consists  of  a  series  of  bones  called  vertebrae, 
connected  by  fibrous  and  elastic  structures  and  in  larger  part 
separated  by  intervertebral  discs.  The  segmentation  of  the 
spine  serves  admirably  the  purpose  for  which  it  was  made,  first, 
to  support  the  upper  part  of  the  body,  the  head,  shoulder  girdle, 


OSTEOPATHIC  MECHANICS  13 

and  torso;  secondly,  to  protect  the  spinal  cord  and  its  membranes 
from  injuries  and  concussions. 

The  number  of  vertebrae  in  the  first  years  of  life  is  thirty- 
three;  according  to  their  connections  they  have  been  divided  into 
groups:  seven  cervical,  twelve  thoracic,  five  lumbar,  five  sacral, 
and  five  coccygeal.  Between  the  fifth  and  tenth  years,  the  lowest 
four  unite  to  form  one  bone,  the  coccyx;  between  the  tenth  and 
twenty-fifth  years,  the  five  sacral  unite  forming  a  solid  bone,  the 
sacrum;  the  remaining  twenty-four  are  called  true  vertebrae 
because  they  remain  separated  in  the  normal  spine  throughout 
life. 

All  the  vertebrae  are  constructed  upon  the  same  general  plan : 

1.  A. strong  body  for  the  transmission  of  weight. 

a.  In  the  lumbar  area,  kidney-shaped,  massive,  deeper 

in  front  than  behind. 

b.  In  the  thoracic  area,  heart-shaped,  deeper  behind 

than  in  front,  diminishing  in  size  gradually  from 
the  twelfth  to  the  third. 

c.  In  the  cervical  area,  small,  ovoid  in  shape,  concave 

transversely  above,  sagitally  below. 

2.  A  neural  arch  to  cover  the  spinal  cord,  divided  arbitrarily 
into 

a.  Pedicles,  containing  intervertebral  notches,  by  the 

opposition  of  which  are  formed  intervertebral 
foramina  for  the  transmission  of  spinal  nerves  and 
blood  vessels. 

b.  Laminae. 

3.  Spinous  and  transverse  processes  for  the  attachment  of 
muscles  and  ligaments;    in  the  thoracic  region  the  transverse 
processes  help  to  support  the  ribs. 

4.  Articular  processes  to  effect  a  junction  of  the  arch  with  that 
of  the  vertebrae  above  and  below,  the  superior  articular  facets  facing 

a.  In  the  cervical  area  backward  and  upward. 

b.  In  the  thoracic  area  backward  and  outward. 

c.  In  the  lumbar  area  backward  and  inward. 

The  interarticular  fibrocartilage  or  disc  is  an  integral  part 
of  the  spinal  articulation.  Its  purpose  is  to  give  elasticity  to  the 
spinal  column,  to  protect  the  spinal  cord  from  jars,  and  at  the 
same  time  to  add  strength  by  connecting  firmly  and  closely  every 
two  segments.  Each  disc  is  composed  of  two  parts,  the  annulus 
fibrosus,  or  annual  fibrous  ring,  the  outer  layer  of  which  is  com- 


14  OSTEOPATHIC  MECHANICS 

posed  of  dense  fibrous  tissue,  the  inner  layer  of  fibrocartilage ; 
the  other  part,  the  nucleus  pulposus,  is  a  pulpy  substance,  highly 
elastic,  tightly  compressed,  so  that  it  acts  as  a  compression  cushion 
upon  which  the  bodies  of  the  vertebrae  may  move.  The  discs 
are  not  wholly  separated  from  the  vertebrae  for  the  reason  that 
they  are  connected  to  the  hyaline  cartilage  which  covers,  and  is 
tightly  adherent  to,  the  surfaces  of  the  bodies. 

While  the  discs  are  shaped  according  to  the  circumference  of 
the  vertebral  bodies,  they  are  unequal  in  depth  in  the  lumbar 
and  cervical  areas,  being  deeper  in  front  than  behind  and  helping 
in  that  way  to  form  the  anterior  convexity  of  the  physiological 
curves  in  those  regions.  In  the  thoracic  area  the  discs  are  shallower 
in  comparison  with  the  bodies  of  the  vertebrae.  Of  the  height  of 
the  entire  spine,  the  discs  constitute  one-fourth. 

The  ligaments  of  a  joint  have  two  functions,  first  to  unite 
the  bones  entering  into  the  joint,  and  secondly,  to  limit  the  move- 
ment of  the  joint.  They  are  strong  bands  of  white  fibrous  tissue, 
pliant  but  inextensile,  and  closely  united  to  the  periosteum  of 
the  bones  they  join.  These  ligaments  are 

1 .  Those  connecting  the  bodies  of  the  vertebrae 

a.  Anterior  longitudinal. 

b.  Posterior  longitudinal. 

c.  Lateral  vertebral.1 

2.  Those  connecting  the  processes 

a.  Supraspinous. 

b.  Interspinous. 

c.  Ligamentum  nuchse. 

d.  Intertrans verse. 

Ligaments  which  fill  up  spaces  or  enter  into  capsules  in  the 
spinal  joints  are  largely  composed  of  yellow  elastic  tissue  and  are 

1.  Capsular. 

2.  Flava. 

The  osteopathist  is  much  concerned  with  the  nature  of  the 
joints  of  the  spinal  column  for  according  to  the  kind  of  movement 
possible  are  the  lesions  either  subluxations  or  traumatic  lesions. 
The  joints  between_the  bodies  of  the  vertebrae  belong  to  the  class 


1.  Morris's  "Human  Anatomy"  (Jackson)  1914. 


OSTEOPATHIC  MECHANICS 

Fig.  1  Fig.  2 


15 


^ 


Fig.  3 

FIGS.  1,  2,  3. — Schematic  drawings  to  illustrate  the  central  point  C  about  which  the 
vertebra  rotates.  Line  A-A  represents  the  arc  bisecting  the  planes  of  the  articular  facets  in 
the  cervical  and  lumbar  areas  and  passing  between  the  facets  in  the  dorsal  area.  Sup.,  superior 
articular  facets;  Inf.,  inferior  articular  facets*.  (After  etchings  in  Ernest  Frazer's  "Anatomy 
of  the  Human  Skeleton. " 

of  amphiarthrodia,1  joints  having  limited  movement.  The  axes 
of  motion  in  the  spinal  articulations  pass  through  the  bodies  of 
the  vertebrae,  which  fact  assures  the  mechanical  stability  of  the 
spinal  column.  It  is  for  this  purpose  that  discs  join  the  bodies 
and  where  the  discs  are  the  thickest  there  is  present  the  greatest 
amount  of  motion  in  the  joints. 

To  the  larger  class  of  arthrodia  belong  the  articular  joints 
and  they  are  characterized  by  a  gliding  of  one  articulating  surface 
upon  the  other,  the  amount  of  movement  being  limited  by  the 
ligaments  and  the  contact  of  osseous  processes.  The  influence  of 

*Frazer's  book  is  probably  the  best  upon  the  osteology  of  man.  It 
was  published  by  P.  Blakiston's  Son  &  Co.,  1914. 

1.  Anatomical  descriptions  in  this  book  will  be  brief,  with  the  supposi- 
tion that  the  student  undertaking  the  subject  has  spent  at  least  one  year  in  a 
thorough  study  of  descriptive  anatomy. 


16 


OSTEOPATHIC  MECHANICS 


the  articular  processes  upon  the  movements  of  the  spinal  column 
may  be  plainly  seen  when  due  consideration  is  given  the  planes1 
of  the  articular  surfaces  which  limit  the  direction  of  inclination 
in  any  given  movement. 

It  is  axiomatic  that  the  bodies  of  the  vertebrae  move  least, 
being  in  and  about  the  center  of  motion;  the  various  processes 
of  the  vertebrae  move  more  in  proportion  as  they  are  farther  away 
from  the  central  axis,  thus:  in  rotation  in  the  dorsal  area  the 
spinous  process  of  the  vertebra  would  move  in  a  larger  arc  than 
any  line  upon  the  posterior  surface  of  the  arch. 

THE  MATTER  OF  EQUILIBRIUM 

The  problem  which  constantly  confronts  man  is  that  of 
maintaining  the  upright  position,  or  stated  in  one  word,  balance. 
The  difficulties  under  which  he  labors  in  holding  himself  erect 
may  be  demonstrated  best  by  a  comparison  between  the  mechanics 
of  the  quadruped's  position  with  that  of  the  human. 

MAN 

Upright 
Two  limbs 
Small 
High 


Spine 

Support 

Base 

Superstructure 

Mass  supported 

Thorax 


QUADRUPED 
Horizontal 
Four  limbs 
Large 
Low 


Moderate 

Swung  between 
supports 

Ribs  fall  into  expan- 
sion 

Ribs  pulled  up 

At  right  angles 

Small 


Large 

Disposed  in  line  of 

weight 
Ribs  pulled  up  and 

thorax  expanded 
Ribs  fall 
In  long  axis 
Great 


Inspiration 

Expiration 

Viscera  carried 

Muscular  effort  nec- 
essary to  main- 
tain balance 

Man's  weight  is  disposed  in  a  plane  at  right  angles  to  that 
for  which  mechanically  it  was  best  adapted,  and  from  the  above 
it  may  thus  be  seen  that  a  large  number  of  factors  enter  into  the 
matter  of  equilibrium  and  that  there  is  required  a  continuous 
adjustment  to  a  constantly  varying  position  of  the  line  of  gravity. 

Balance  is  reflex,  instinctive  and  is  maintained  by  means  of 

1.  The  planes  of  the  articulating  surfaces  are  of  the  utmost  importance 
in  the  consideration  of  any  articulation. 


OSTEOPATHIC  MECHANICS 


17 


co-ordinated  muscular  action.  Due  to  the  segmentation  of  the 
body,  there  is  a  constant  shifting  of  weight  forces  and  the  individual 
must  be  able  to  keep  his  center  of  gravity  over  the  center  of 
support  or  lose  the  symmetry  normal  to  the  upright  position. 
The  sum  of  man's  experiences  in  maintaining  equilibrium  con- 
stitutes what  is  termed  his  posture,  attitude,  standing  position. 

The  carriage  of  the  body  at  any  given  period  of  life  is  resultant 
upon  the  individual's  struggles  with  the  influences  of  environment, 
occupation,  diseases  that  weaken  the 
organism,  strains,  fatigue,  climatic 
conditions,  etc.  It  is  most  notice- 
able in  a  disturbance  in  the  curves 
of  the  spine  which  are  directly  the 
effect  of  man's  effort  to  attain  the 
upright  position. 

The  normal  spine  has  four  physi- 
ological curves.  Two  are  primary, 
and  are  so  called  because  they  ap- 
pear within  the  first  year  of  life,  and 
two  are  secondary,  the  result  of  the 
child's  struggle  to  maintain  his  body 
in  the  erect  position.  The  sacral 
and  dorsal  curves  are  the  primary 
ones;  the  cervical  curve  is  brought 
about  by  the  carriage  of  the  head, 
and  the  lumbar  curve  is  established 
after  the  child  has  learned  to  walk. 

The  secondary  curves  are  counterbal-    process  of  tho  lowest  vertebra' 
ancing  and  may  be  almost  wholly  obliterated  by  placing  the  patient 
in  suspension,  taking  the  weight  of  his  trunk  off  from  his  spine. 

There  is  the  same  relation  between  lesions  that  there  is 
between  curves,  primary  and  secondary,  and  the  secondary  lesion 
is  always  for  the  purpose  of  restoring  erectness  or  equilibrium.  A 
primary  lesion  may  be  defined  as  one  that  originates  independently 
of  any  other  lesion.  A  secondary  lesion  is  one  that  follows  a 
primary  lesion  and  is  compensatory  or  counterbalancing  in 
character.  They  are  further  distinguished  by  the  functional  test 
of  mobility.  A  primary  lesion  is  an  immobilization  of  a  joint 


FIG.  4. — A  part  of  the  dorsal  area  of 
the  spine  showing  a  deflected  spinous 


18  OSTEOPATHIC  MECHANICS 

wherein  movement  is  restricted  or  lost.  A  secondary  lesion  may 
show  slight  limitations  of  motion  but  it  is  not  to  be  characterized 
as  a  lesion  in  the  sense  of  complete  immobilization.  It  may 
disappear  in. flexion  or  extension,  in  forced  rotation  or  sidebend- 
ing.  At  rest  it  appears  like  a  primary  lesion.  Its  diagnosis  is 
made  by  palpation  which  is  the  province  of  the  osteopathist. 

OSTEOPATHIC  DIAGNOSIS  is  the  science  and  art  of  finding  and 
defining  abnormalities  in  organs  and  tissues.  It  embraces  not 
alone  physical  diagnosis  but  that  peculiar  science  originated  by 
Andrew  Taylor  Still  which  seeks  to  find  in  spinal  maladjustment  a 
potent  etiological  factor  in  the  production  of  disease.  Osteopathy 
has  brought  to  perfection  the  art  of  palpation.  By  it  the  osteo- 
pathist is  able  to  detect  the  minutest  deviation  from  the  normal 
in  structural  relations  and  physiological  action. 

OSTEOPATHIC  TECHNIQUE  consists  in  definite  operations  for 
the  precise  adjustment  of  structural  deviations  and  for  the  regu- 
lation of  functional  perversions.  As  a  part  of  Osteopathic 
Mechanics  it  is  concerned  with  the  execution  of  definite  manual 
procedures  in  exact  accord  with  mechanical  laws.  To  these  laws 
has  been  given  the  term,  principles  of  correction. 

A  corrective  movement  is  one  that  has  for  its  purpose  the 
adjustment  of  lesion.  A  lesion  that  has  been  adjusted  has  been 
removed.  The  secondary  effects,  near  and  remote,  have  no 
further  etiological  foundation;  but  if  due  to  habits  of  unbalance 
they  persist,  they  may  be  overcome  by  the  same  principles  of 
correction  that  would  be  applied  to  primary  lesions. 

Anatomies  have  established  certain  rules  for  the  ready  recog- 
nition of  spinal  areas  and  certain  vertebrae.  In  his  study  of  the 
spine  of  the  living  subject,  the  student  will  find  them  of  great 
value. 

SPINOUS  PROCESS. 

7th  cervical prominent,  differentiated  from  the  1st  thoracic 

by  the  disappearance  of  the  spine  of  the 
6th  in  extension  of  the  head. 

3d  dorsal opposite  the  root  of  the  spine  of  the  scapula. 

7th  dorsal opposite  the  inferior  angle  of  the  scapula. 

Tip  of  process 

Dorsal  area at  the  level  of  the  vertebral  body  next  below. 

Upper  dorsal  ....  corresponds  to  the  head  of  the  rib  next  below. 


OSTEOPATHIC  MECHANICS  19 

Middorsal corresponds  with  the  disc  between  the  two 

vertebral  bodies  next  below  its  own  body. 
1 1th  and  12th  .  .  .  opposite  the  heads  of  the  corresponding  ribs. 

4th  lumbar level  with  the  highest  points  of  the  crests  of 

the  innominates. 

Any  lumbar level  with  the  disc  below  the  same  vertebra. 

Third  sacral level  with  the  posterior  superior  spines  of  the 

innominates. 

In  osteopathic  technique,  the  seventh  cervical  vertebra  is 
regarded  as  a  thoracic  vertebra,  and  the  twelfth  thoracic  as  a 
lumbar  vertebra.  Each  of  these  functionally  belongs  to  the  latter 
class  rather  than  to  the  one  of  anatomical  selection. 

The  principle  of  the  lever  is  the  one  most  commonly  used  in 
the  adjustment  of  lesions,  with  that  of  the  inclined  plane,  the 
wedge,  occasionally  employed.  There  are  three  classes  of  levers 
in  the  human  body  just  as  there  are  in  machines,  but  in  osteopathic 
mechanics  the  term  fixed  point  has  largely  replaced  the  term  ful- 
crum and  in  this  book  the  extremities  of  the  weight  and  power  arms 
are  designated  usually  as  points  of  attack. 

Standardization  is  the  purpose  of  most  of  our  recent  researches 
in  the  mechanics  of  osteopathy  but  we  are  being  constantly  brought 
face  to  face  with  the  fact  that  the  mechanical  powers  of  the  human 
body  vary  in  degree  if  not  in  kind  and  that  the  problems  are  yet 
far  from  being  completely  solved. 


Bibliography:     Cunningham's  Anatomy,  pg.  91-95;   299-309. 

Deaver's  Surgical  Anatomy,  Vol.  I,  pg.  412-419. 

Frazer,  ibid,  Chap.  II. 

Gray's  Anatomy,  pg.  259-273. 

Lovett's  Lateral  Curvature  of  the  Spine,  Chap.  I. 

Morris's  Anatomy,  pg.  31-38,  211-215,  225-232. 


20  OSTEOPATHIC  MECHANICS 

CHAPTER  II. 
THE  NORMAL  MOVEMENTS  OF  THE  SPINE 

The  normal  human  spine  is  capable  of  three  movements: 
(1)  flexion;  (2)  extension,  and  (3)  a  compound  movement,  rotation- 
sidebending  or  sidebending-rotation. 

FLEXION 

Flexion  is  secured  by  bending  the  body  forward,  inclining 
the  head  upon  the  chest,  the  torso  and  pelvis  upon  the  thighs. 
The  back  shows  a  marked  posterior  curve  but  the  spinal  column 
itself  has  less  of  true  flexion  than  appears  in  the  bent  body.  The 
amount  of  flexion  present  in  any  spine  may  be  measured  by  a 
tape-line,  preferably  one  of  steel.  Apply  one  end  of  the  tape  to 
the  tip  of  any  spinous  process  with  the  subject  sitting  in  the  erect 
position.  Measure  the  distance  between  that  spinous  process  and 
a  certain  one  below.  Then  ask  the  subject  to  bend  forward  in 
extreme  flexion  and  measure  the  distance  between  the  same  spinous 
processes.  The  difference  in  the  two  amounts  will  represent  the 
extent  of  flexion  present  in  that  area. 

The  amount  of  flexibility  in  any  spine  differs  at  different 
periods  in  the  life  cycle.  Certain  occupations  and  diseases  pre- 
dispose to  early  rigidity.  If  a  man  is  as  old  as  his  spine  is  rigid, 
by  comparison  we  should  be  able  to  give  a  fairly  accurate  guess 
as  to  his  chances  for  longevity. 

Flexion  is  accomplished  in  the  spinal  joint  by  the  gliding 
upward  and  slightly  forward  of  the  inferior  articular  facets  upon 
the  superior  articular  facets  of  the  vertebra  below.  Simultaneously 
the  intervertebral  disc  is  compressed  anteriorly  and  widened 
posteriorly,  becoming  wedge-shaped  with  the  base  of  the  wedge 
posterior.  The  posterior  ligaments  of  the  articulation  are 
stretched.  Due  to  the  consistency  of  the  disc  and  to  the  pull  of 
muscles  producing  flexion,1  the  anterior  inferior  margin  of  the 

1.  Flexion  of  the  spine  is  produced  by  the  action  of  the  following  muscles: 
sterno-cleido-mastoid,  rectus  capitis  anticus  major,  longus  colli  et  capitis, 
scaleni,  psoas  magnus,  psoas  parvus,  and  the  abdominal  muscles. 


OSTEOPATHIC  MECHANICS  21 

body  of  the  upper  vertebra  projects  slightly  anterior  to  the 
anterior  superior  margin  of  the  vertebra  below  so  that  as  a  unit 
the  vertebra  may  be  said  to  have  moved  slightly  forward. 

By  reason  of  the  approximation  of  the  bodies  of  the  vertebrae 
to  which  it  is  attached,  the  anterior  longitudinal  ligament  becomes 
somewhat  relaxed  and  should  the  articulation  become  immobilized 
in  this  position,  adaptive  shortening  and  thickening  would  result. 

It  is  a  matter  of  muscular  and  ligarnentous  tone  how  much 
movement  takes  place  between  the  articular  facets  of  any  spinal 
joint.  Experience  confirms  the  opinion  that  the  movement  is 
complete  when  the  lower  one-third  of  the  inferior  articular  facet 
remains  in  apposition  with  the  upper  one-third  of  the  correspond- 
ing superior  facet.  Much  less  than  this  amount  is  common  to 
the  average  spine. 

In  the  cervical  and  lumbar  areas  flexion  is  free;  in  the  thoracic 
area  of  the  spine  flexion  is  restricted,  due  to  the  attachment  of 
the  ribs;  especially  is  this  true  of  the  upper  six  thoracic  articula- 
tions. 

Flexion  subluxations  are  common  to  the  lumbar  and  thoracic 
areas  but  infrequent  in  the  cervical  region  for  the  reason  that 
blows  to  the  skull  or  other  strains  are  more  likely  to  cause  lesions 
of  the  occipitoatloid  or  cervicodorsal  articulations. 

EXTENSION 

Extension  is  a  backward  bending  of  the  spinal  column  and 
is  a  restricted  movement  throughout  the  entire  spine,  due  to  (1)  • 
the  interference  of  bony  processes,  and  (2)  to  the  tenacity  of  the 
anterior  longitudinal  ligament.  It  is  the  least  common  of  the 
movements  of  the  spine  beyond  the  action  of  making  erect  the 
spinal  column  after  flexion.  The  spinal  articulations  are  rarely 
carried  beyond  the  normal  apposition  of  articulating  surfaces,  that 
apposition  which  is  present  when  man  sits  or  stands  erect.  The 
amount  of  extension  in  any  area  may  be  determined  by  measure- 
ment with  the  tape. 

Extension1  is  accomplished  in  the  spinal  articulation  by  a 

1.  Extension  in  the  spinal  column  is  the  result  of  the  action  of  the  follow- 
ing muscles:  splenius  capitis  et  cervicis,  spinalis,  sacrospinalis,  semispinalis 
capitis,  cervicis,  et  dorsi,  multifidus,  rotatores,  levatores  costarum,  inter- 
transversarii,  and  quadratus  lumborum. 


22  OSTEOPATHIC  MECHANICS 

gliding  backward  of  the  inferior  articular  facets  upon  the  superior 
articular  facets  of  the  vertebra  below  and  is  a  movement  of  very 
slight  extent.  Simultaneously  the  intervertebral  disc  is  com- 
pressed posteriorly  and  stretched  anteriorly,  so  that  it  becomes 
slightly  wedge-shaped  with  the  base  of  the  wedge  anterior.  The 
anterior  longitudinal  and  the  lateral  vertebral  ligaments  are 
stretched  and  the  posterior  ligaments  relaxed.  Should  immobili- 
zation in  this  position  occur,  the  posterior  group  of  ligaments 
would  in  time  become  shortened  and  thickened.  The  inferior 
anterior  margin  of  the  body  of  the  vertebra  does  recede  slightly 
from  the  anterior  superior  margin  of  the  vertebra  below,  so  that 
the  vertebra  as  a  unit  is  actually  slightly  posterior  to  the  vertebra 
below. 

Extension  is  free  in  the  cervical  and  lumbar  areas,  but  restrict- 
ed in  the  dorsal  area.  Extension  subluxations  are  found  in  the 
thoracic  and  lumbar  areas;  very  rarely  in  the  cervical  region. 

ROTATION 

Rotation,1  it  has  been  stated,  is  always  one  part  of  a  com- 
pound movement,  the  other  part  being  sidebending.  The  reason 
for  the  union  of  these  two  movements  is  found  in  the  mechanism 
of  the  spinal  column  as  a  whole.  The  spine  is  not  composed  of  a 
series  of  rectangular  cubes  disposed  in  parallel  lines  upon  a  central 
axis  of  rotation.  It  is  rather  a  series -of  wedges,  bony  and  carti- 
laginous, united  quite  firmly  together  by  tenacious  bands  which 
help  to  maintain  these  wedges  in  physiological  curves,  which 
have  been  determined  by  the  shape  of  the  component  parts  and 
preserved  in  the  living  body  by  the  integrity  of  muscles  and 
ligaments.  They  act  together  as  a  flexible  rod,  which  being  bent 
in  one  plane  cannot  be  turned  in  another  without  twisting.  The 
constant  expression  of  this  torsion  is  secondary  sidebending  when 
rotation  is  the  initiative  movement,  and  is  secondary  rotation 
when  sidebending  is  the  initiative  movement. 

The  human  spine  responds  to  rotation  differently  in  different 
areas  depending  upon  the  plane  of  the  articulating  surfaces  and 


1.  For  detailed  description   see  Robert  W.  Lovett's  "Lateral  Curvature 
of  the  Spine,"  2nd  edit.,  page  29. 


OSTEOPATHIC  MECHANICS 


23 


upon  the  position  of  the  spine,  whether  erect,  flexed,  or  hyper- 
extended. 

EXPERIMENT  I. — Ask  the  subject,  whose  back  should  be  well 
exposed,  to  sit  upon  a  stool  and  hold  the  spine  comfortably  erect. 
He  may  place  his  hands  upon  his  head,  elbows  forward,  to  spread 


FIG.  u. — The  artificial  production  of  a  rotation  curvature.    The  hand  of  the  demonstrator 
who  is  turning  the  subject  to  the  right  is  indicated  by  the  cross.    This  illustrates  experiment  I. 

the  scapulae.  Direct  the  subject  to  turn  his  head  and  torso  to  the 
right  and  ask  him  to  hold  the  position.  A  curvature  will  be  seen 
in  the  thoracic  area,  from  the  first  to  the  tenth  vertebras  inclusive, 
with  the  convexity  of  the  curve  to  the  left,  the  concavity  to  the 
right.  Further  examination  shows  a  prominence  of  the  ribs  upon 


24 


OSTEOPATHIC  MECHANICS 


the  right  and  a  flattening  of  the  ribs  upon  the  left.  To  determine 
this,  it  may  be  necessary  to  stand  above  the  patient  and  look 
down  upon  his  back,  making  a  comparison  between  the  two  sides. 
The  greatest  deviation  from  the  normal  will  be  found  at  the  apex 
of  the  curve.  Dr.  Lovett  and  others  have  designated  the  side  of 
the  prominent  ribs  as  the  high  side,1  in  contradistinction  to  the 
flattening  that  has  taken  place  upon  the  other  side. 

This  experiment  demonstrates  that  the  bodies  of  the  thoracic 
vertebrae  have  turned  toward  the  right,  the  concavity  of  the  curve; 


FIG.  6.— The  rjbs  of  a  person  facing  forward  are  indicated  in  Fig.  I.     The  person  who 
rotates  his  trunk  to  the  right  turns  the  vertebrae  and  ribs  as  indicated  by  Fig.  II. 

the  spinous  processes  have  turned  in  a  reverse  direction ;  in  turning, 
the  right  transverse  processes  were  compelled  to  move  backward, 
the  left  ones- forward;  the  ribs  articulating  with  the  right  trans- 
verse processes  were  pulled  backward,  and  those  upon  the  left 
side  were  pushed  forward  by  the  rotation  forward  of  the  transverse 
processes  on  that  side. 

Further,  if  the-bodies  of^hevertebrsEJ-otated  to  the  concavity 
of  the  curve,  and  that  concavity  was  upon  the  right,  then  the 
right  transverse  processes  must  have  approached  one  another; 
the  converse  is  true,— if  the  left  transverse  processes,  the  side  of 
the  convexity,  took  part  in  the  general  sidetilting  of  the  vertebras 
then  they  must  have  been  separated  and  are  further  apart,  one 

1.  The  term  high  side  has  been  so  universally  adopted  and  is  so  well 
understood  that  it  will  not  be  placed  in  quotation  marks  in  this  book. 


OSTEOPATHIC  MECHANICS  25 

from  another.     The  corresponding  ribs  would  also  manifest  the 
same  changes. 

EXPERIMENT  II. — Let  the  demonstrator  stand  to  the  right 
side  of  the  subject  and  grasping  him  by  the  shoulders,  forcibly 
rotate  him  further  to  the  right.  It  will  be  observed  that  rotation 
may  thus  be  made  to  take  place  in  the  lumbar  area. 

In  a  subject  with  a  flexible  spine,  forcible  rotation  would  be 
without  danger,  but  in  those  whose  spines  were  more  or  less  rigid, 
it  would  be  possible  to  produce  traumatic  rotation  lesions  among 
the  lumbar  articulations. 

The  lumbar  area,  with  the  subject  in  the  erect  position,  is 
locked  against  rotation. 

EXPERIMENT  III. — With  the  subject  seated,  direct  him  to 
bend  forward  in  moderate  flexion  and  then  to  rotate  the  trunk  as 
before.  The  area  that  responds  to  rotation  is  less  in  extent  than 
in  the  erect  position.  Greater  flexion  still  further  restricts  it, 
until  in  the  position  of  extreme  forward  flexion,  it  is  doubtful  if 
rotation  exists  lower  than  the  third  thoracic.  The  high  side  is 
upon  the  concavity,  showing  that  the  vertebral  bodies  have  rotated 
to  the  concavity. 

By  forward  flexion,  the  lower  thoracic  and  lumbar  areas  are 
locked  against  rotation. 

EXPERIMENT  IV.— Place  straps  across  the  subject's  thighs, 
attached  to  rings  in  the  floor,  so  that  his  pelvis  may  be  fixed  and 
he  shall  have  no  sensation  of  unbalance  in  any  position.  Ask 
the  subject  to  carry  his  torso  back  in  extension.  Direct  him  to 
turn  his  body  to  the  right.  It  may  be  plainly  seen  that  the  torso 
as  a  whole  has  rotated  upon  an  axis  at  the  dorsolumbar  junction. 
In  the  average  subject  rotation  in  hyperextension  takes  place 
between  the  eleventh  thoracic  and  the  second  lumbar  only.  The 
same  signs  are  present  as  in  rotation  in  the  erect  position.  The 
high  side  in  the  lumbar  area  is  produced  by  the  pushing  backward 
of  the  muscle  mass  by  the  transverse  processes. 

Forcible  rotation  with  a  patient  in  this  position  might  pro- 
duce a  traumatic  lesion  among  the  lower  lumbar  articulations. 

By  hyperextension  the  upper  and  middorsal  and  the  lower 
lumbar  areas  are  locked  against  rotation. 

Rotation  in  the  cervical  area  is  largely  a  matter  of  the  atlanto- 
axial  articulation,  but  may  be  effected  among  the  cervical  joints 
and  is  present  in  the  occipitoatloid  articulation  in  extreme  rotation 

3 


26  OSTEOPATHIC  MECHANICS 

of  the  head.     We  shall  consider  here  rotation  as  it  occurs  in  the 
cervical  area. 

EXPERIMENT  V. — With  the  subject  sitting,  the  demonstrator 
stands  behind  him  and  places  both  thumbs,  one  over  the  other, 
upon  a  cervical  spinous  process,  preferably  the  sixth  cervical. 
He  then  pushes  aside  the  sternocleidomastoid  muscles  and  places 
the  radial  side  of  the  index  fingers  against  the  anterior  tubercles 
of  the  transverse  processes  from  the  axis  to  the  sixth  cervical.  It 
is  easier  for  some  demonstrators  to  place  the  cushions  of  the  finger 
tips  upon  the  same  bony  processes,  to  which  no  objection  can  be 
made  if  the  pressure  exerted  is  exceedingly  light.  Palpation  is 
more  successful  the  lighter  the  application  of  force,  a  fact  often 
ignored  by  students. 

Ask  the  subject  to  turn  his  face  slowly  to  the  right.  Immedi- 
ately it  is  to  be  noticed  that  the  distance  between  the  thumb  and 
the  fingers  of  the  left  hand,  antero-posteriorly,  is  greater  than 
that  between  the  thumb  and  fingers  of  the  right  hand;  that 
while  there  has  been  an  increase  upon  the  left  there  has  been  no 
appreciable  change  in  the  distance  upon  the  right.  Ask  the 
subject  to  turn  the  face  again  to  the  front  and  repeat  the  experi- 
ment. Note  subsequently  that  the  vertical  height  upon  the  left 
has  increased,  upon  the  right  there  is  apparently  a  slight  decrease 
and  careful  palpation  may  explain  the  fact  since  a  curvature  may 
now  be  detected  in  the  cervical  region  with  the  concavity  upon 
the  right,  the  convexity  upon  the  left. 

Ask  the  subject  to  flex  the  head  forward  and  attempt  rotation, 
whereupon  it  will  be  found  that  flexion  limits  cervical  rotation. 
Ask  him  to  hyperextend  the  head,  and  again,  hyperextension  will 
be  found  to  limit  rotation,  though  not  as  perceptibly  as  flexion 
limits  it. 

By  the  increase  of  depth  antero-posteriorly  upon  the  left,  it 
has  been  demonstrated  that  the  left  transverse  processes  have 
moved  forward,  which  in  turn  signifies  that  the  bodies  have  rotated 
toward  the  right,  the  side  of  the  concavity  of  the  curve.  The 
unchanged  condition  of  depth  upon  the  right  demonstrates  that 
the  axis  of  motion  for  cervical  rotation  is  a  vertical  one  passing 
through  the  articular  facets  upon  that  side.  The  presence  of 
convexity  upon  the  left  and  concavity  upon  the  right  demonstrates 
that  secondary  sidebending  has  taken  place.  The  increased  height 
vertically  upon  the  left,  together  with  the  increased  depth  antero- 
posteriorly  upon  the  same  side,  demonstrates  that  each  inferior 
articular  facet  upon  the  left  has  moved  upward  and  forward  upon 
the  corresponding  superior  articular  facet  of  the  vertebra  below. 

We  may  summarize  our  conclusions: 


OSTEOPATHIC  MECHANICS 


27 


I.     In   rotation-sidebending,    the   bodies   of   the   vertebrae 
rotate  to  the  concavity  of  the  curve. 

II.     The  high  side  is  upon  the  concavity. 

III.  Each  vertebra  as  a  whole  has  tilted  and  rotated  toward 
the  right. 

a.  The  right  transverse  process  has  moved  backward  and 

has  approached  the  one  below. 

b.  The  left  transverse  process  has  moved  forward  and 

has  separated  from  the  one  below. 

IV.  Flexion  lessens  rotation  from  below  upward. 

V.  Hyperextension  lessens  rotation  in  the  cervical  area  and 
in  the  dorsal  and  lumbar  areas  restricts  rotation  to  the  dorso- 
lumbar  junction  only. 


FIG.  7. — This  represents  the  concave  torsion  in  the  lumbar  area  in  sidebending.in  the  erect 
position.     The  cross  is  placed  upon  tin?  high  side.     This  illustrates  experiment  VI. 


28  OSTEOPATHIC  MECHANICS 

SIDEBENDING 

Initiative  sidebending1  is  accompanied  by  secondary  rotation. 
It  is,  therefore,  not  a  simple  movement  of  the  spine  but  part  of  a 
compound  movement.  In  other  texts,  it  has  been  spoken  of  as 
lateral  flexion,  or  as  abduction. 

EXPERIMENT  VI. — Ask  the  subject  seated  upon  the  stool,  with 
pelvis  fixed  by  straps  across  the  thighs  fastened  to  rings  in  the 
floor,  to  bend  sidewise  to  the  right.  For  the  purpose  of  exact 
observation,  add  support  beneath  the  right  shoulder  so  that  the 
subject  shall  expend  no  muscular  effort  to  prevent  falling.  This 
is  particularly  essential  since  the  foreign  orthopedists  have  failed 
to  draw  tenable  conclusions  in  regard  to  the  conduct  of  the  verte- 
brae in  sidebending.  The  human  spine  behaves  much  better  in 
experimentation  when  freed  from  undue  muscular  action. 

A  curvature  is  seen  in  the  lumbar  area  of  the  spine,  including 
the  last  two  or  three  thoracic  spinous  processes,  concave  to  the 
right,  with  the  high  side  upon  the  concavity  of  the  curve.  Figure 
7  represents  what  is  seen  in  this  experiment.  Spinal  columns 
having  more  rigidity  will  react  less  completely  to  sidebending  in 
this  position. 

EXPERIMENT  VII. — With  the  subject  and  demonstrator  as -in 
experiment  V,  ask  the  subject  to  bend  the  head  to  the  right, 
increased  vertical  height  among  the  transverse  processes  and  the 
convexity  of  a  curve  may  be  palpated  upon  the  left,  with  no  appre- 
ciable change  save  the  formation  of  the  concavity  of  a  curve  on 
the  right.  Ask  the  subject  to  raise  the  head  and  repeat  the  side- 
bending.  Palpating  for  change  in  the  depth  antero-posteriorly, 
it  may  be  noted  that  there  is  present  some  increase  upon  the  left 
but  no  appreciable  change  upon  the  right.  The  results'  of  this 
experiment  are  so  constant  in  respect  to  the  signs  with  that 
obtained  in  the  study  of  rotation,  that  we  may  adopt  the  same 
conclusions. 

EXPERIMENT  VIII. — With  the  patient  seated  as  in  experi- 
ment VI,  ask  him  to  hyperextend  the  spine  and  then  bend 
laterally.  A  curvature  is  seen  in  the  lower  lumbar  area  and  the 
high  side  is  on  the  concavity  of  the  curve. 

Hyperextension  limits  sidebending  to  the  lumbar  area  and 
the  thoracic  area  by  hyperextension  is  locked  against  sidebending. 

EXPERIMENT  IX. — With  the  subject  seated,  ask  him  to  bend 
forward  in  moderate  flexion  and  then  to  sidebend  his  torso  to  the 
right.  A  curvature  appears  convex  to  the  left,  concave  to  the  right, 
in  extent  from  the  first  to  the  eighth  or  tenth  thoracic.  The 
high  side  is  upon  the  left. 

1.  See  Lovett,  ibid,  p.  25. 


OSTEOPATHIC  MECHANICS  29 

Since  the  high  side  means  that  side  toward  which  the  bodies 
of  the  vertebrae  have  rotated,  it  is  to  be  remarked  in  this  instance 
that  the  bodies  of  the  vertebrae  have  rotated  to  the  convexity  of 
the  curve.  The  left  transverse  processes  have  moved  backward, 
the  right  transverse  processes  have  moved  slightly  forward ;  while 
the  spinous  processes  form  the  convexity  of  the  curve  upon  the 
left,  each  by  the  turning  of  the  vertebral  body  has  turned  in  a 
reverse  direction  toward  the  right,  a  point  to  be  remembered  in 
the  consideration  of  the  subluxation  of  a  single  vertebra  in  flexed 
sidebending-rotation . 

Each  vertebra  taking  .part  in  the  sidebending  has  sidetilted 
to  the  right  but  is  rotated  toward  the  left.  Due  to  its  position, 
the  right  transverse  processes  approach  one  another,  the  left 
transverse  processes  are  separated.  The  inter  vertebral  disc  between 
any  two  of  the  vertebrae  is  compressed  upon  the  right,  stretched 
upon  the  left. 

The  reason  for  the  rotation  to  the  left  is  due  to  the  fact  that 
in  flexion  the  bodies  of  the  vertebrae  have  by  the  compression  of 
the  discs  anteriorly  been  brought  together.  Sidebending  adds 
compression  upon  the  discs  on  the  right  and  the  bodies  of  the 
vertebrae  responding  to  the  combination  of  forces  move  in  the 
path  of  least  resistance,  the  convexity  of  the  curve. 

We  may  summarize  our  conclusions: 

I.  Sidebending-rotation  in  the  erect  position  occurs  in  the 
dorsolumbar  and  cervical  areas  only. 

II.  The  bodies  of  the  vertebrae  rotate  to  the  side  of  the  con- 
cavity. 

III.  Flexion  lessens  sidebending  in  extent  to  the  upper  and 
middorsal  areas,  and  the  bodies  of  the  vertebrae  rotate  to  the  side 
of  the  convexity. 

a.  Each  vertebra  as  a  whole  has  tilted  toward  the  right 
and  rotated  toward  the  left. 

1.  The  right  transverse  process  is  approximated  to 

the  one  below. 

2.  The  left   transverse   process   is   prominent   and 

separated  from  the  one  below. 

IV.  Hyperextension  lessens  sidebending  in  extent,  confines 
it  to  the  lumbar  area  of  the  spine,  and  the  bodies  of  the  vertebrae 
rotate  to  the  concavity  of  the  curve.     The  twelfth  dorsal  acts  as 
a  lumbar  vertebra,  a  fact  that  has  been  noted  before. 


30  OSTEOPATHIC  MECHANICS 

CHAPTER  III. 
LATERAL  CURVATURE  OF  THE  SPINE 

Lateral  curvature1  of  the  spine  is  a  condition  in  which  there 
is  a  lateral  deviation  with  torsion  of  a  series  of  vertebral  bodies 
from  the  mesial  plane  of  the  body.  The  spinous  processes  appear 
as  a  curved  line  in  the  back.  The  curvature  is  constant  in  the 
erect  position  and  is  -distinguished  as  functional  or  postural  when 
it  disappears  in  recumbency  and  as  structural  when  it  is  permanent 
in  whatsoever  position  the  body  may  be  placed. 

Curvature  was  recognized  by  the  ancients,  who  gave  much 
consideration  to  the  causal  factors  and  the  mechanical  problems 
in  correction.  Hippocrates  in  the  fourth  century  B.  C.  was 
probably  the  first  writer  to  describe  curvature  of  the  spine.  With 
him  originated  the  term  scoliosis,  from  a  Greek  word  meaning 
to  twist  or  bend.  He  gave  as  his  opinion  that  the  first  cause  of 
scoliosis  was  a  dislocation  of  a  vertebra.  This  was  the  accepted 
idea  for  many  centuries.  Ambroise  Pare,  in  the  first  half  of  the 
sixteenth  century,  not  only  presented  many  arguments  in  favor 
of  this  theory  but  also  claimed  a  spinal  subluxation  origin  for 
most  diseases.  In  1641,  Riolan,  in  France,  advanced  as  causal 
factors,  the  wearing  of  clothing  with  improper  constrictions  and 
the  excessive  use  of  the  right  arm.  Glisson  in  1660  suggested 
rickets  as  an  additional  cause.  Andre,  the  man  who  gave  to  the 
world  the  word,  "orthopedic,"2  writing  in  1741,  ascribed  curva- 


1.  Bibliography. — Lateral  Curvature  of  the  Spine,  R.  W.  Lovett,  second 
edition,  1912.     P.  Blakiston's  Son  &  Co.,  Philadelphia. 

Scoliosis,  George  M.  Laughlin.  1914.  American  School  of  Osteopathy, 
Kirksville,  Mo. 

Orthopedic  Surgery,  Royal  Whitman,  1910.     Lea  &  Febiger,  Philadelphia. 

Surgery,  Principles  and  Practice,  A.  P.  C.  Ashhurst.  1914.  Lea  & 
Febiger,  Philadelphia. 

The  American  Journal  of  Orthopedic  Surgery,  July,  1913.  P.  Blakiston's 
Son  &  Co.,  Philadelphia. 

Lateral  Curvature  of  the  Spine  and  Fiat-Foot,  J.  S.  K.  Smith,  1911.  Wm. 
Wood  &  Co.,  New  York. 

2.  "  L'Orthopedie  est  1'art  de  prevenir  et  de  corriger  dans  les  enfants  les 
deformities  du  corps."       The  word  comes  from  two  Greek  words  meaning 
"straight"  and  "child". 


OSTEOPATHIC  MECHANICS  31 

ture  to  the  use  of  high  heels,  bad  sitting  postures,  and  the  irritation 
of  hemorrhoids.  In  1779,  Percival  Pott,  an  English  physician, 
eliminated  caries  of  the  spine  from  the  general  classification  of 
scoliosis,  and  on  account  of  his  researches  into  that  condition, 
left  a  memory  of  his  work  in  the  common  name  for  tuberculosis 
of  the  spine,  Pott's  disease.  Wullstein,  a  decade  ago,  added 
much  to  the  understanding  of  the  mechanics  underlying  the  pro- 
duction of  curvature  by  his  experiments  with  the  spines  of  young 
dogs.  Boehm  in  1906  by  separating  the  etiology  of  scoliosis  into 
congenital  and  acquired  classes,  called  attention  to  malformations 
of  bone  as  a  primary  cause. 

FUNCTIONAL  CURVATURE 

The  line  of  gravity  which  represents  the  concentration  of  the 
weight  forces  acting  upon  the  body,  is  constantly  shifting  because 
the  body  is  a  segmented  structure.  Man  must  be  able  to  adjust 
the  segments  one  to  another  momentarily  to  maintain  his  equilib- 
rium. This  action  is  reflex,  instinctive,  and  depends  upon  his 
having  a  normal  body  and  an  intact  nervous  system.  Let  dis- 
turbance in  either  take  place  and  curvature  is  an  early  effect.  Its 
mechanism  follows  definite  laws  and  may  be  demonstrated  by  a 
study  of  functional  curvatures  experimentally  produced  and  by 
inductive  reasoning  and  an  examination  of  patients  presenting 
the  structual  type  of  curvature. 

In  the  study  of  the  normal  movements  of  the  spine,  we  have 
seen  that  in  the  erect  position  either  rotation  or  sidebending, 
when  held  immobilized  for  the  purpose  of  observation,  presents 
a  curve  in  the  spine  with  the  constant  sign  of  the  high  side  on  the 
concavity. 

Careful  examination  of  a  patient  with  the  functional  type  of 
curvature  will  reveal  that  such  a  case  presents  the  same  picture  so 
that  we  may  conclude  that  as  a  result  of  partial  immobilization  the 
vertebra  remain  twisted  in  curvature  and  that  the  production  has 
been  in  accord  with  the  mechanical  laws  governing  the  movements 
of  the  spine,  sidebending  in  the  lumbar  area,  rotation  in  the  dorsal 
area.  The  question  to  be  answered  is  what  may  be  the  force  or 
cause  resulting  in  immobilization. 


32  OSTEOPATHIC  MECHANICS 

EXPERIMENT  I. — Place  upon  the  floor  a  brick  or  block  of  wood 
three  or  four  inches  in  height.  Ask  the  subject  to  stand,  with 
his  weight  equally  divided,  with  the  right  foot  upon  the  block, 
the  left  foot  upon  the  floor  at  a  distance  of  eighteen  inches  away 
from  the  block.  A  curvature  in  the  dorsolumbar  area  is  produced, 
with  the  concavity  to  the  right.  The  high  side  is  upon  the  con- 
cavity, showing  that  the  vertebral  bodies  have  rotated  to  that 
side.  The  right  hip  is  noticeably  prominent,  the  waist-line 
apparently  deeper,  while  upon  the  left  side  the  hip  is  less  prominent, 
the  waist-line  seemingly  shallower.  We  have  here  the  counter- 
part of  a  patient  with  a  postural  curvature  in  the  same  area. 

By  this  experiment  it  has  been  demonstrated  that  one  of  the 
causes  may  be  a  lengthening  of  one  of  the  supporting  sides,  or  the 
same  effect  could  be  produced  by  shortening  the  other  side. 

Any  one  of  the  following  causes  would  operate  in  the 
same  way:  sacroiliac  lesion;  flat-foot;  stiff  knee  or  ankle  from 
arthritis,  tuberculosis,  or  other  infective  process;  contraction  of 
muscles  from  pain,  as  in  sciatica  or  in  abscess  formation ;  fracture ; 
dislocation;  alteration  in  soft  tissues  as  in  cicatrix  or  growth; 
muscular  atrophy  or  spasticity  from  paralysis;  difference  in  the 
length  of  the  bones  of  the  leg,  or  congenital  malformations. 

Faulty  habits  enter  largely  into  the  production  of  curvature. 
There  are  postures  in  standing,  sitting,  and  lying  which  if  main- 
tained for  any  considerable  length  of  time,  cause  adaptive  muscular 
shortening  upon  one  side,  with  the  formation  of  a  concavity  later- 
ally in  the  spinal  column.  Some  of  these  habits  are  the  result  of 
carelessness,  some  are  due  to  fatigue,  mental  or  physical ;  some  to 
weakness  from  diseases  which  lower  the  general  vitality  of  the 
body  as  malnutrition,  rachitis,  lack  of  oxygenation,  and  digestive 
ailments;  some  to  occupations  requiring  the  individual  to  hold  a 
part  of  his  body  in  a  position  of  strain  for  hours  at  a  time;  some  to 
errors  of  refraction  or  disturbance  in  hearing  in  one  ear.  School 
furniture  may  be  a  cause  in  not  suiting  the  size  of  the  child  who 
sits  for  hours  in  the  classroom.  Blackboards  having  upon  them 
a  lesson  to  be  copied  may  be  placed  at  one  side  instead  of  in  front 
of  the  child. 

Of  the  habits  which  result  in  postural  curvature  of  the  dorso- 
lumbar area  may  be  mentioned  standing  with  the  weight  upon 
one  foot,  sitting  on  the  foot,  or  with  a  knee  crossed  over  the  other, 


OSTEOPATHIC  MECHANICS  33 

sleeping  upon  the  side  with  the  head  high  or  with  the  shoulder 
lifted  by  a  pillow.  These  are  common  faults  in  adults  and  hence 
nearly  all  those  who  develop  the  dorsolumbar  lateral  curvature 
after  the  age  of  twenty  do  so  from  one  of  these  causes. 

Children  err  in  attitudes  from  shyness,  restlessness,  or  weak- 
ness. They  react  to  uncomfortable  clothing  by  a  twist  or  a  bend. 
Tight  clothing  across  the  chest  prevents  the  normal  development 
of  the  spinal  musculature.  A  tight  armhole  will  cause  a  child  to 
carry  the  shoulder  high.  Straps  too  far  out  upon  the  shoulders 
where  weight  should  not  be  placed  during  the  years  of  growth, 
cause  a  sagging  of  the  shoulders  and  indirectly  a  dropping  of  one 
more  than  the  other.  An  ill-fitting  shoe  may  be  the  first  cause  of 
inequality  of  support  from  the  base.  Children  are  clever  imitators, 
unconsciously  to  a  great  extent.  They  easily  fall  into  the  faulty 
postures  of  their  parents  or  teachers. 

Not  all  faults  in  habit  lead  to  lateral  curvatures  for  accom- 
panying growth  there  is  usually  development  of  strength  and  in 
athletic  sports  and  games,  action  is  demanded  of  all  muscles  with 
the  result  that  the  lagging  one  reacts  strongly  to  stimuli  and  in 
time  equilibrium  is  restored. 

Dorsolumbar  lateral  curves  may  be  due  to  horseback-riding 
with  a  side-saddle.  Sitting  at  ease  in  a  slumped  position  against 
the  arm  of  a  chair  while  reading  or  sewing  is  a  frequent  source  of 
postural  curvature  in  middle-aged  women.  The  congenital 
anomaly  of  a  lumbar  rib  is  a  cause  of  unbalance  in  that  region  of 
the  spine  with  subsequent  lateral  curvature. 

Weight  is  the  primary  factor  in  the  production  of  all  curva- 
tures. Experiments  have  been  made  with  cadavers  upon  whose 
shoulders  have  been  placed  heavy  loads,  usually  of  eighty  pounds. 
A  bending  forward  of  the  dorsal  area,  an  increased  lordosis  in  the 
lumbar  region,  were  immediate  results,  followed  by  lateral  bending 
or  rotation.  Ever  so  slight  an  increase  in  the  weight  on  one  or 
the  other  side  brings  out  a  lateral  curvature. 

The  carrying  of  the  head,  shoulder  girdle,  and  thorax  does  not 
seem  much  in  itself,  but  in  the  presence  of  weakness,  the  load  is 
greater  than  the  muscles'  strength  can  bear.  It  may  be  stated  as 
a  corollary  that  the  spine  is  only  as  strong  as  its  weakest  muscle. 
It  follows  that  any  disturbance  in  the  musculature  would  cause 


34  OSTEOPATHIC  MECHANICS 

an  immediate  disturbance  in  the  spinal  articulations  controlled 
by  that  muscle.  Antagonistic  action  of  flexors  and  extensors 
maintains  the  spine  erect.  Antagonistic  action  of  the  muscles  of 
the  two  sides  of  the  spine  prevents  lateral  bending.  Let  one  muscle 
in  any  group  be  paralyzed  or  injured  to  the  extent  of  lost  tone  and 
unbalance  will  result.  Curvature  is  the  gross  effect  of  disturbed 
equilibrium. 

Sometimes  at  birth  certain  muscles  have  been  found  paralyzed 
and  that  individual  necessarily  grows  up  with  unavoidable  curva- 
ture, usually  structural  in  type.  In  the  same  way  later  paralysis. 
anterior  poliomyelitis,  when  it  manifests  paralysis  of  the  spinal 
muscles,  causes  a  lateral  curvature.  Any  irritation  located  in  the 
back  or  lateral  thoracic  wall  will  cause  an  inequality  in  the  action 
of  the  spinal  muscles  and  thoracic  curvature  will  result.  Among 
such  causes  may  be  found  lesions  or  fractures  of  the  ribs;  empyema 
usually  followed  by  a  resection  of  a  rib;  pleuritic  inflammations, 
abscesses,  or  adhesions;  wounds;  scars;  intercostal  neuraliga; 
appendicitis;  ovarian  and  uterine  diseases  causing  pain  upon  one 
side,  and  disease  of  a  kidney. 

Curvatures  in  the  upper  thoracic  or  cervical  areas  are  not  as 
common  as  those  below.  Any  inequality  in  the  weight  of  the 
head  or  interference  with  the  carriage  of  the  shoulder  girdle  pre- 
disposes to  changed  relations  among  the  vertebrae.  The  causes 
recognized  by  osteopathic  physicians  are  lateral  occipital  lesions, 
lateral  atlas  lesions,  anterior  cervical  lesions,  torticollis,  injuries 
to  the  shoulder  joint  causing  pain  and  disturbance  in  mobility, 
inflammations  in  the  head  as  mastoiditis  or  of  the  lateral  chain  of 
cervical  lymphatics.  A  cervical  rib,  a  congenital  anomaly,  almost 
always  causes  an  irritation  which  leads,  by  the  individual's  effort 
in  securing  relief  in  a  changed  position  or  carriage,  to  curvature  at 
the  cervicothoracic  junction. 

From  the  causes  above  given  no  definite  time  can  be  stated 
as  that  wherein  there  would  be  the  complete  development  of  either 
the  functional  or  structural  type  of  curvature.  Rapidity  of 
change  from  the  normal  is  marked  in  the  frail  child,  the  anemic 
girl,  the  lazy  man  or  woman  who  has  faulty  habits  of  posture. 
Environment,  nutrition,  fresh  air,  systematic  exercise,  all  are 
factors  in  delaying  the  progress  of  any  case.  Except  in  a  few  cities 


OSTEOPATHIC  MECHANICS  35 

where  compulsory  examination  of  the  spines  of  school  children  is 
required,  curvatures  are  not  discovered  early  but  rather  at  the 
beginning  of  adolescence  when  a  dressmarker  or  a  tailor  remarks 
upon  the  presence  of  a  high  hip  or  low  shoulder.  It  is  not  usually 
then  that  a  spinal  examination  is  made.  Later,  only  when  by 
reason  of  the  remark  of  some  friend  or  relative  that  there  seems  to 
be  some  distortion  in  the  patient's  body,  does  the  patient  seek 
advice.  As  the  treatment  for  the  two  types  of  curvatures  is 
entirely  unlike,  a  careful  examination  must  be  made  and  the 
diagnosis  be  established  without  doubt. 

Functional  curvature  may  be  defined  as  a  partial  immobiliza- 
tion of  a  part  of  the  spine  in  a  position  of  physiological  lateral 
bending  or  rotation.  It  occurs  in  all  areas  of  the  spine  and  is  named 
according  to  the  convexity  of  the  curve  and  the  area  wherein  it 
appears.  A  right  cervical  curve  means  a  curve  convex  to  the 
right  in  the  cervical  area  of  the  spine  as  seen  from  behind  the 
patient.  Others  are  named  accordingly: 

Right  cervicodorsal :  convexity  to  the  right,  curve  among  the 
lower  cervical  and  upper  dorsal  vertebrae. 

Right  dorsal :  convexity  to  the  right,  curve  among  the  dorsal 
vertebrae. 

Right  dorsolumbar :  convexity  to  the  right,  curve  among  the 
lower  dorsal  and  upper  lumbar  vertebrae. 

Right  lumbar:  convexity  to  the  right,  curve  in  the  lumbar 
area. 

A  long  postural,  total,  or  functional  curvature  is  one  involving 
practically  all  of  the  lumbar  and  dorsal  areas,  in  extent  usually 
from  the  upper  or  middorsal  region  to  the  lumbosacral  joint.  It 
is  one  that  is  common  among  women  between  the  ages  of  twenty 
and  forty  as  the  result  of  a  faulty  habit  in  standing  or  sitting. 
The  patients  are  otherwise  quite  healthy. 

The  characteristics  of  a  left  total  curve  are  as  follows : 

1 .  A  curve  of  the  dorsal  and  lumbar  areas  with  the  convexity 
to  the  left. 

2.  The  high  side  is  on  the  right. 

3.  The  left  shoulder  is  elevated. 

4.  The  right  side  of  the  shoulder  girdle  has  been  carried  back- 
ward and  the  left  side  forward. 


36  OSTEOPATHIC  MECHANICS 

5.  Lateral  flexion  to  the  right  is  freer  than  lateral  flexion  to 
the  left. 

6.  The  curvature  disappears  upon  recumbency. 

In  a  case  of  long  standing,  as  in  the  class  of  patients  of  the 
age  of  forty,  sometimes  the  curvature  does  not  entirely  disappear 
upon  assuming  the  prone  position,  which  is  a  manifestation  of  the 
strength  of  the  contractures  of  the  muscles  on  the  side  of  the 
concavity. 

When  a  total  curve  appears  in  a  child  or  adolescent,  it  does 
not  always  remain  of  that  type.  That  which  usually  happens  is  a 
transition  to  the  double  or  figure-S  curve,  occasionally  to  the 
triple  curve.  The  second  curve  is  due  to  the  subconscious  efforts 
of  the  patient  to  square  his  shoulder  girdle  with  his  pelvis.  It  is 
plain  from  the  above  description  of  a  patient  with  a  total  curvature 
that,  in  order  to  face  forward  in  standing  or  walking,  he  must 
either  twist  his  pelvis  and  legs,  or  otherwise  he  must  face  to  the 
right  slightly  at  all  times  when  in  the  erect  position.  Without 
conscious  effort  he  turns  that  portion  which  is  more  easily  moved, 
the  shoulder  girdle.  In  so  doing  he  elevates  the  right  shoulder 
and  rotates  it  to  the  front,  he  depresses  1  he  left  shoulder  and  turns 
it  backward,  and  he  rotates  the  bodies  of  the  vertebrae  from  the 
right  to  the  left,  producing  by  the  law  of  rotation  a  curve,  concave 
to  the  left,  with  the  high  side  upon  the  concavity.  There  are  then 
present  two  curves  in  the  spine,  one  to  the  left  in  the  dorsolumbar 
area,  and  one  to  the  right  in  the  upper  dorsal  area  and  sometimes 
including  the  cervicodorsal  area. 

EXPERIMENT  II. — With  the  subject  standing  with  one  foot 
upon  the  block  and  the  other  on  the  floor,  as  in  experiment  I, 
after  the  spine  has  settled  into  a  left  dorsolumbar  or  total  curva- 
ture, ask  the  subject  to  square  his  shoulders  with  his  pelvis  by 
turning  the  shoulder  girdle  to  the  left.  It  may  be  necessary  for 
him  to  fold  his  arms  across  his  chest  or  clasp  his  hands  behind  his 
neck  in  order  to  expose  the  interscapular  area  for  observation.  A 
curve  will  be  found  in  the  dorsal  area,  of  less  extent  than  the  one 
below  and  having  all  the  characteristics  of  a  physiological,  simple 
dorsal  curve. 

In  the  patient  with  a  like  condition  the  curves  are  much  more 
easily  detected  for  the  reason  that  there  have  been  muscular 
shortenings  which  preserve  the  changed  relations  whenever  the 


OSTEOPATHIC  MECHANICS  37 

spine  is  held  in  the  erect  position.  In  many  of  these  patients, 
with  a  Webster  record,1  a  little  of  the  double  curve  remains  when 
the  patient  assumes  the  prone  position.  This  shows  that  the 
muscular  contractions  on  the  concavities  are  very  strong. 

Double  curves  are  named  according  to  the  convexit}^  and  the 
area;  a  right  lumbar  left  dorsal  curve  would  be  interpreted  to 
mean  a  curvature  in  the  lumbar  area  with  the  convexity  to  the 
right  and  a  curvature  in  the  dorsal  area  with  the  convexity  to  the 
left.  Triple  curves  are  designated  in  the  same  way,  are  less  fre- 
quent than  the  double  curves,  and  usually  involve  the  lower 
cervical  area  or  the  cervicodorsal  junction  in  the  uppermost  of  the 
three  curves. 

EXPERIMENT  III. — Repeat  experiment  II.  At  its  conclusion 
ask  the  subject  to  bend  forward  in  moderate  flexion.  The  curve 
remains  and  the  rotation  of  the  bodies  does  not  change. 

By  the  maintenance  of  inequality  in  base,  there  is  the  same 
amount  of  pull  on  the  vertebra?  that  there  would  be  in  a  functional 
curve  of  long  standing  with  the  muscles  on  the  concavity  contrac- 
tured. 

EXAMINATION   OF  A  PATIENT  WITH  CURVATURE 

The  usual  age  of  the  patient  brought  to  a  physician  for  treat- 
ment for  curvature  is  from  five  to  twenty-one.  In  this  country 
the  larger  number  of  these  patients  are  females  but  abroad  where 
military  service  is  demanded  of  all  healthy  males,  the  percentage 
is  stated  to  be  twenty-four  males  to  every  seventeen  females. 

The  patient  should  have  the  entire  back  bared  with  only  a 
thin  covering  over  the  chest  so  that  each  dorsal  segment  may  be 
examined  in  detail.  For  females  a  short  skirt  gathered  into  an 
elastic  band  at  the  waist  is  the  best  apparel.  For  males  short 
trousers  are  to  be  preferred,  for  examination  of  the  feet  in  the 
standing  position  is  an  essential. 

1.  Dr.  C.  G.  Webster  of  Carthage,  N.  Y.,  has  devised  an  excellent  method 
of  preserving  records  of  the  spines  of  the  patients  he  examines.  The  patient 
is  placed  prone  upon  a  flat  table,  with  the  head  hanging  over  at  one  end.  A 
wide  strip  of  adhesive  tape  is  applied  to  the  spine.  Markings  about  the 
spinous  processes  are  then  made  with  an  indelible  pencil  which  has  not  too 
sharp  a  point.  The  plumb-line  is  then  used  to  sketch  the  normal  sagital  line 
of  the  trunk.  The  tape  is  removed  and  deviations  verified  by  osteopathic 
palpation  of  the  vertebral  processes. 


38  OSTEOPATHIC  MECHANICS 

The  physical  condition  should  be  first  taken  into  account, 
nutrition,  size,  development  according  to  statistics  for  age,  color, 
respiratory  capacity,  condition  of  the  heart,  pulse,  vision  in  each 
eye,  hearing  of  each  ear,  general  carriage  of  the  body,  condition 
of  the  arches  of  the  feet,  comparison  of  the  length  of  the  legs,1 
manner  of  dress  with  especial  attention  to  the  way  the  under- 
clothing and  hosiery  are  supported.  The  nervous  condition  of 
the  patient  may  be  arrived  at  after  the  manner  of  the  average 
tests  applied  in  the  examination  of  such  patients. 

While  the  case  history  is  being  recited,  observation  should  be 
made  of  the  patient  who  is  asked  to  sit  at  ease.  If  he  has  faulty 
posture  in  sitting,  it  will  be  manifest  after  the  first  embarrassment 
wears  off.  Ask  him  to  walk  across  the  room  and  stand  with  his 
back  toward  the  physician.  Two  or  three  minutes  later  relaxa- 
tion will  take  place  and  he  will  manifest  those  signs  which  brought 
him  for  examination.  Then  should  follow  the  determination  of 
the  actual  condition. 

Standing  in  front,  the  physician  notes — 

A.  Lack  of  symmetry  in  the  general  outline  of  the  body. 

1.  1'he  trunk  shows  a  lateral  displacement. 

2.  One  shoulder  may  be  higher. 

3.  One  hip  is  more  prominent. 
Standingjbehind  the  patient  it  may  be  noted  that — 

B.  A  curvature  exists  in  the  spine. 

1.  Area  of  involvement. 

2.  The  presence  of  a  high  side 

a.  Upon  the  concavity. 

b.  Upon  the  convexity. 

C.  The  position  of  the  scapulae  and  their  relative  distance 

from  the  spine. 

D.  The  position  of  the  head,  whether  held  in  rotation  or 

sidebending. 

Standing  above  the  patient  and  looking  down  upon  his  back,  one 
should  note — 

E.  The  relation  of  the  shoulder  girdle  to  the  pelvic  girdle, 

whether  one  is  square  with  the  other,  or  whether  one 
shoulder  has  rotated  forward,  the  other  backward. 

1.  The  length  of  the  legs  may  be  fairly  correctly  measured  by  placing 
one  end  of  a  steel  tape-line  at  the  anterior  superior  spine  of  the  ilium  and 
noting  the  distance  to  the  internal  malleolus  of  the  leg  of  the  same  side.  The 
usual  method  of  comparing  the  length  by  measuring  the  heels  together  is 
inexact  and  unreliable. 


OSTEOPATHIC  MECHANICS  39 

A  perpendicular  or  plumb-line  should  then  be  erected  from  the 
cleft  between  the  buttocks  and  held  by  one  end  at  a  point  repre- 
senting the  top  of  the  spinal  column.  A  line  may  be  traced  down 
the  middle  of  the  back  with  a  dermatographic  pencil  for  the  esti- 
mation of  the  deviation  of  the  apex  of  each  curve  from  the  median 
line  of  the  back.  If  the  patient  has  a  double  curve,  the  extent  of 
each  curve  should  be  noted  and  a  record  of  all  the  findings  made. 

The  patient  should  then  be  asked  to  bend  forward  in  flexion 
and  again  the  physician  should  note — 

F.  The  permanency  of  the  curve, 

1.  It  disappears. 

2.  It  is  materially  lessened. 

3.  It  does  not  change. 

G.  The  patient  stands  with  his  feet  apart,  bends  forward  and 

the  same  notations  are  made  regarding  the  permanency 

of  the  curve. 
H.  The  Say  re  head-sling  is  applied,  weight  is  taken  off  from 

the  spine,  and  the  same  notations  are  made. 
I.  The  patient  is  asked  to  lie  prone  upon  the  table  and  again 

its  permanency  or  lack  of  permanency  is  noted. 

Records  may  be  made  by  photograph  or  by  X-radiance,  in 
each  case  with  the  patient  sitting  with  support  applied  laterally 
to  the  thorax  so  that  the  position  may  be  held  with  ease  and  without 
wavering.  A  modification  of  the  Webster  record  has  been  used 
by  the  author  for  keeping  permanent  records  of  the  spines  of  these 
patients.  The  adhesive  tape  is  applied  with  the  patient  seated, 
with  his  chest  and  forehead  supported  by  photographer's  rests, 
with  the  arms  crossed  in  the  lap.  As  the  case  responds  to  treat- 
ment, other  records  may  be  made  and  will  serve  as  tests  of  com- 
plete correction.  These  are  of  value  chiefly  in  making  records  of 
the  functional  type  of  curvature. 

The  differential  diagnosis  of  a  functional  curvature  is  estab- 
lished by  the  presence  of  the  following  signs : 

1.  The  high  side  upon  the  concavity  of  the  curve. 

2.  Complete  disappearance  of  curvature  in  the  prone  position. 

TREATMENT 

The  osteopathic  treatment  of  functional  curvature  is  mani- 
festly more  successful  than  that  of  any  other  school  of  therapeutics 
for  the  reason  that  with  the  basic  understanding  which  every 
physician  of  the  osteopathic  school  has  of  the  mechanics  of  the 


40  OSTEOPATHIC  MECHANICS 

human  body,  he  best  knows  how  to  remove  the  cause,  how  to 
correct  the  deviation  of  anatomical  parts  by  the  scientific  applica- 
tion of  mechanical  laws,  and,  following  the  re-establishment  of  nor- 
mal relations,  how  to  advise  against  a  return  of  the  former  condition. 

To  remove  the  cause  is  the  first  essential  and  treatment  for 
such  a  purpose  is  to  be  classified  as  adjustive,  surgical,  or  postural, 
according  to  what  the  cause  is.  Lesions  must  be  adjusted,  growths 
and  congenital  anomalies  removed,  tendons  transplanted  whenever 
possible  for  the  sake  of  changing  paralyzed  conditions,  defective 
eyesight  or  hearing  given  attention,  inequalities  of  base  overcome 
by  lifts  in  the  shoes,  raised  heels,  or  the  adjustment  of  a  flat  arch. 
In  the  changing  of  habits  of  attitude,  the  physician  must  secure 
the  cooperation  of  the  patient  for  without  it  little  can  be  accom- 
plished that  is  permanent.  Patients  should  be  impressed  with  the 
importance  of  overcoming  these  faults  and  also  be  warned  that 
any  return  to  them  will  result  in  a  recurrence  of  the  curvature. 

If  the  condition  of  health  in  the  patient  is  poor,  the  treatment 
must  begin  in  a  general  upbuilding.  In  youth  curvature  that  is 
not  severe  little  affects  the  bodily  vigor  but  in  later  life  as  the 
spinal  column  becomes  more  rigid  and  the  intervertebral  discs 
atrophy,  the  curves  increase  in  severity  and  tend  to  induce  pain 
in  the  back  and  discomfort  from  the  sense  of  the  lack  of  symmetry. 
Where  the  cause  seems  to  be  due  to  fatigue,  the  child  must  be 
taken  out  of  school  and  given  outdoor  life  with  an  entire  change 
of  environment  wherever  possible.  The  same  advice  may  be 
given  to  the  older  patient. 

Since  weight  is  a  large  factor  in  producing  and  increasing 
curvature,  a  greater  number  of  hours  of  rest  in  recumbency  should 
be  taken  for  the  purpose  of  giving  the  distorted  spine  more  rest 
from  the  weight  of  the  head  and  shoulder  girdle. 

We  may  not  speak  of  the  osteopathic  treatment  administered 
to  cases  with  functional  curvature  as  adjustive.  It  is  corrective 
in  character  being  directed  toward  the  reversing  of  the  curves  in 
accord  with  the  laws  of  the  normal,  physiologic  movements  of  the 
spine.  Because  of  the  adaptive  shortening  of  the  ligaments  and 
the  contractures  of  the  muscles  on  the  side  of  the  concavity,  the 
patient  is  not  able  to  help  himself  by  exercise  alone,  for  it  is  a 
well-known  fact  that  the  soft  tissues  of  the  passive  body  are  more 
easily  stretched  than  those  of  the  active  individual. 


OSTEOPATHIC  MECHANICS  41 

The  process  of  bringing  the  spine  back  to  the  normal  is  of 
necessity  a  gradual  one.  The  shortening  of  ligaments  and  muscles 
has  been  mentioned  and  offers  one  of  the  first  problems  in  treat- 
ment. The  author  does  not  favor  massage  but  in  its  stead  recom- 
mends stretching  of  muscle  fasciculi  and  ligaments  by  forcible 
separation  of  origin  and  insertion  which  may  be  effected  by  putting 
the  spine  through  flexion  and  extension  and  by  reversing  the 
rotation  and  sidebending  present  in  the  curvature.  The  fibro- 
cartilages  show  an  adaptive  compression  on  the  concavity  and  by 
the  same  means  will  be  brought  toward  the  normal. 

The  most  important  reason  why  the  overcoming  of  curvature 
should  not  be  forced  is  that  the  type  of  patient  with  such  a  condi- 
tion will  not  warrant  it.  The  commonest  cases  are  those  of  children 
of  all  ages  from  the  little  prattling  lad  who  is  yet  in  a  somewhat 
unstable  equilibrium  upon  his  feet  to  the  high  school  boy  or  girl. 
These  children  have  had  an  unequal  chance  in  the  game  of  early 
achievement.  They  have  been  frail  else  the  curvature  would  not 
have  appeared.  The  first  necessity,  then,  in  treatment  is  that  it 
shall  not  be  rough,  that  it  shall  not  hurt.  Children  react  to 
pain  more  quickly  than  adults,  and  pain,  it  should  be  remembered, 
prevents  voluntary  relaxation,  produces  reflex  contractions,  and 
hinders  correction. 

CORRECTIVE  MOVEMENTS 

PRINCIPLES  OF  CORRECTION. — IN  THE  LUMBAR  AREA  SIDE- 
BEND  THE  PATIENT  TO  THE  CONVEXITY.  IN  THE  DORSAL  AREA 

ROTATE  THE  PATIENT  TO  THE  CONVEXITY. 

GENERAL  RULES. — STRETCH  THE  CONCAVITY  AND  MAKE  A 
NEW  CONCAVITY  ON  THE  CONVEXITY,  or  what  in  effect  is  the  same 
thing,  make  a  new  convexity  of  the  side  of  the  concavity. 

A  patient,  B,  is  assumed  to  have  a  lumbar  functional  curva- 
ture, convex  to  the  left. 

I.  THE  CREEPING  MOVEMENT. l — Let  B  support  his  trunk  in 
the  horizontal  position  with  his  hands  and  knees  on  the  table. 

1.  This  corrective  movement  is  so  named  because  it  is  like  in  principle 
a  valuable  exercise  for  a  patient  afflicted  with  a  lumbar  curvature,  convex  to 
the  left.  The  exercise  consists  in  the  patient's  creeping  in  a  circle  with  the 
side  of  the  concavity  outward.  See  Lovett,  ibid,  page  145,  exercises  XXV, 
XXVI,  and  XXVII. 


42 


OSTEOPATHIC  MECHAX  i  <  s 


FIG.  8. — Corrective  movement  I  for  a  lumbar  functional  curvature  convex  to  the  left. 

He  advances  the  left  knee  and  places  the  left  hand,  palm  down- 
ward, fingers  pointing  backward,  beside  it.  The  right  knee  is 
moved  backward  and  the  right  hand  is  extended  beyond  the  head 
with  the  palm  downward  and  the  fingers  pointing  forward.  In  this 
position  the  left  hand  and  knee  are  close  together  and  the  right 
hand  and  knee  some  distance  apart.  The  physician,  O,  stands  at 
the  right  side  of  B.  He  places  both  arms  under  B's  abdomen  and 
grasps  the  side  of  B's  thorax  and  waist  with  his  hands.  O's 
right  shoulder  rests  in  B's  right  axilla  as  a  point  of  attack,  O's 
left  shoulder  rests  against  the  crest  of  B's  right  ilium  as  a  second 
point  of  attack. 

O  pulls  B  towards  him  and  at  the  same  time  he  separates  by 
strong  pressure  the  points  of  attack,  first,  to  produce  a  new  con- 
cavity on  the  side  of  the  convexity,  and  secondly  to  stretch  the 
concavity  to  the  fullest  extent. 

This  corrective  movement  should  be  repeated  several  times 


OSTEOPATHIC  MECHANICS 


43 


at  each  treatment  and  the  patient  may  be  advised  to  take  the 
position  and  attempt,  unaided,  the  movement  at  home  between 
treatments. 

II.  HYPEREXTENSION  SIDEBENDING  MOVEMENT. l — Let  the 
patient  lie  upon  the  table  prone,  with  the  trunk  above  the  waist 
projecting  over  the  end  of  the  table,  with  the  arms  extended 


FIG.  9. — Corrective  movement  II,  for  a  lumbar  functional  curvature  convex  to  the  right. 

beyond  the  head  and  resting  upon  O's  forearm,  O  standing  upon 
the  side  of  the  convexity  of  the  curve.  O  lifts  B  into  a  position  of 
extension2  and  bends  his  body  laterally  at  the  waist-line  toward 
O,  while  with  the  other  hand  O  makes  pressure  against  the  spinous 
processes  of  the  lumbar  vertebrae  from  the  side  of  the  convexity 


1.  Patients  relax  better  in  some  positions  and  in  response  to  certain 
motions,  therefore   the   student   should   execute  with  ease  more    than  one 
operative  movement  for  each  condition. 

2.  This  movement  is  too  heavy  for  any  but  light-weight  patients. 


44  OSTEOPATHIC  MECHANICS 

with  the  purpose  of  assisting  in  the  attempt  to  make  a  new  con- 
cavity on  the  side  of  the  convexity. 

Resume. — Sidebending  is  localized  in  the  lumbar  area  by 
hyperextension  and  the  dorsal  area  is  locked  by  hyperextension 
against  sidebending. 

III.  SlDEBENDING-RoTATION    MOVEMENT. — Let   the   patidll 

sit  upon  a  stool  of  suitable  height  facing  O  who  presses  against 
B's  knees  with  the  purpose  of  fixing  B's  pelvis.  O's  right  hand  is 
placed  down  upon  B's  left  shoulder,  grasping  the  shoulder  firmly 
as  a  point  of  attack.  O's  left  hand  passes  under  B's  right  axilla 
to  rest  upon  his  right  shoulder  blade,  while  B  rests  his  right  arm 
upon  O's  left  arm.  By  pulling  upward  with  the  left  hand  and 
pushing  downward  with  the  right  hand,  O  may  bend  B  laterally 
to  the  left,  and  then  slightly  rotate  his  trunk  to  the  same  side. 

Resume. — Sidebending  in  the  lumbar  area  is  accompanied 
by  secondary  rotation  to  the  same  side,  hence  as  a  corrective  move- 
ment in  the  lumbar  area  rotation  must  always  follow  initiative 
sidebending. 

A  patient,  B,  is  assumed  to  have  a  thoracic  curvature,  convex 
to  the  right. 

IV.  COUNTERPRESSURE  MOVEMENT. — Let  B  sit  on  the  end 
of  the  table.     O  stands  to  the  right  and  slightly  in  front  of  B  and 
passes  his  right  arm  across  B's  chest,  under  the  axilla,  and  rests 
his  hand  upon  the  angles  of  the  ribs  at  the  apex  of  the  thoracic 
curve.     O  places  a  small,  firm  pillow  between  his  chest  and  the 
left  anterior  surface  of  B's  thorax  over  the  ribs  diagonally  in  rela- 
tion to  the  area  covered  by  O's  right  hand.     O  reinforces  his  right 
hand  with  his  left  and  exerts  pressure  in  a  straight  line  between 
the  hands  and  the  pillow  gradually  while  B  inhales  with  a  full 
respiration.     Let  B  hold  his  breath  for  a  moment  while  O  holds 
the  pressure.     As  soon  as  O  and  B  act  synchronously,  add  rotation 
to  the  right  at  the  moment  of  maximum  pressure. 

V.  ROTATION  RIB-LEVERAGE  MOVEMENT. — Let  the  patient 
sit  on  the  end  of  the  table.     O  stands  to  the  left  of  B  and  places 
his  left  hand  upon  B's  right  shoulder.     O's  right  hand  rests  strongly 
upon  the  angles  of  the  ribs  on  the  high  side  at  the  apex  of  the  curve. 
O  rotates  B's  torso  to  the  right  by  the  pressure  on  the  right  shoulder 
and  the  left  ribs. 


OSTEOPATHIC  MECHANICS 


45 


FIG.   10. — Corrective  movement  V  for  a  thoracic  functional  curvature  convex  to  the  left. 

Fig.  10  illustrates  this  corrective  movement  for  a  thoracic- 
curvature  the  reverse  of  the  one  here  described. 

VI.  SIMPLE  ROTATION  MOVEMENT. — Let  the  patient  sit  on 
the  end  of  the  table  and  cross  his  arms  across  his  chest  with  his 
hands  on  his  shoulders.  O  stands  to  the  right  of  B  grasping  B's 
left  shoulder,  or  stands  to  the  right  and  slightly  posterior  to  B 
grasping  with  his  right  hand  B's  left  elbow.  O  places  the  thumb 
and  thenar  eminence  of  his  left  hand  to  the  right  side  of  the  spinous 
processes  of  the  vertebrae  at  the  area  of  greatest  de  iation  from  the 
mesial  line  of  the  trunk  with  firm  pressure  against  the  spinous 
processes,  while  pulling  on  B's  left  shoulder  or  elbow,  he  rotates 
B's  torso  to  the  right. 


46  OSTEOPATHIC  MECHANICS 

This  movement  may  be  varied  by  having  B  reflex  forward 
moderately  before  the  execution  of  the  movement  if  the  curvature 
is  located  in  the  upper  thoracic  area  but  the  movement  must  be 
one  of  pure  rotation  following  initiative  flexion. 

VII.  ROTATION-SIDEBENDING  MOVEMENT. — Let  the  patient 
sit  on  the  end  of  the  table.  O  stands  at  B's  right  side  and  bends 
forward.  B  sits  erect  and  turns  slightly  to  rest  his  arms  across  O's 
back.  O  passes  his  right  arm  across  B's  chest,  under  his  axilla, 
until  the  right  hand  rests  over  the  angles  of  the  most  prominent 
ribs.  O  reaches  under  his  left  axilla  with  his  left  hand  and  grasps 
B's  right  wrist.  O  rotates  B's  trunk  farther  to  the  right  and  then 
sidebends  him  to  the  point  of  resistance. 

CONCLUSION 

In  treatment  each  segment  may  be  considered  separately 
with  the  corrective  movement  localized  for  that  segment.  In 
cases  in  which  certain  articulations  are  less  flexible  than  others, 
attention  may  be  directed  in  this  manner  to  those  segments. 

There  is  a  certain  kind  of  auxiliary  treatment  that  is  very 
beneficial  in  these  cases.  It  consists  in  breathing  exercises  in  con- 
nection with  pressure  against  the  angles  of  the  ribs  on  the  high 
side.  The  patient  with  the  thoracic  curve  convex  to  the  right,  is 
asked  to  lie  pon  the  face  on  the  table.  O  rests  his  hands  over 
the  ribs  on  the  high  side  and  exerts  five  to  twenty  foot-pounds  of 
pressure  against  the  ribs  at  the  end  of  B's  full  inspiration,  and 
maintains  the  pressure  while  B  holds  his  breath,  relaxing  the 
pressure  at  the  first  third  of  expiration.  The  amount  of  pressure 
to  be  exerted  is  to  be  determined  by  the  age  and  strength  of  the 
patient.  The  patient  may  take  the  same  exercise  at  home  by  the 
use  of  sandbags  of  proper  weight  and  applied  in  the  same  place. 

No  treatment  should  be  given  without  re-examination1  of  the 
patient,  for  there  comes  a  time,  late  in  the  history  of  the  case 
when  it  requires  the  closest  scrutiny  to  detect  that  a  curvature 
exists.  This  is  when  by  treatment  it  has  been  almost  entirely 
overcome.  Therefore,  it  is  necessary  to  see  the  spine  to  watch  the 
progress  of  the  case  else  at  the  close  there  would  be  danger  of  over- 

1.  The  student  should  analyze  again  and  again  and  at  each  treatment  the 
curves  his  patient  presents  with  a  view  to  an  exact  understanding  of  the 
mechanics  of  production  and  correction.  Repetition  brings  skill. 


OSTEOPATHIC  MECHANICS  47 

correcting,  that  is,  causing  a  reverse  curvature  to  the  opposite 
side.  In  short  there  is  no  condition  wherein  carelessness  in  treat- 
ment can  work  greater  harm.  If  perchance  rotation  or  sidebend- 
ing  were  given  to  the  concavity,  the  curvature  would  be  made  worse. 

Cervical  curvature  is  usually  a  secondary  condition,  following 
lesions  of  the  occipitoatloid  articulation  or  an  upper  thoracic 
primary  curvature.  In  any  case  treatment  should  be  directed 
to  the  correction  of  the  primary  condition,  after  which  the  second- 
ary or  counterbalancing  curve  will  take  care  of  itself.  Should 
it  persist,  however,  treatment  may  be  given  in  accord  with  the 
general  principle  of  correction,  rotation  or  sidebending  in  the 
reverse  direction. 

The  after-treatment  of  functional  curvature  is  exceedingly 
important  for  as  ounces  of  prevention  are  worth  more  than  pounds 
of  cure,  so  is  proper  exercise  and  the  removal  of  the  cause  vital 
to  the  permanency  of  the  curvature  correction.  Atonic  muscles 
must  be  stimulated  to  normal  tone.  It  is  not  safe  for  some  time 
following  cure  to  allow  the  patient  to  enter  a  gymnasium  for  the 
reason  that  the  average  case  requires  personal  attention  and 
suitable  exercises.  During  the  latter  part  of  the  course  of  treat- 
ment, resistance  exercises  should  be  given  for  home  exercise,  as  for 
example,  a  patient  having  a  thoracic  curvature  convex  to  the 
right  might  strengthen  the  atonic  muscles  on  the  convexity  by 
forcibly  rotating  the  shoulders  and  torso  to  the  right.  A  successful 
plan  has  been  to  have  such  a  patient  stand  with  back  to  the  jamb 
of  an  open  door  and  ask  him  to  attempt  to  push  the  door-jamb 
away  by  turning  his  right  shoulder  backward. 

Following  correction,  the  exercises  should  be  those  of  flexion, 
extension,  and  creeping  in  a  forward  direction,  principally  because 
these  movements  make  use  equally  of  the  muscles  of  both  halves 
of  the  trunk  at  the  same  time. 

SCOLIOSIS 

Of  the  two  types  of  spinal  malposition,  functional  curvature 
is  the  one  which  any  normal  spine  may  assume;  structural  curva- 
ture has  no  exact  prototype  in  any  position  which  the  normal  spine 
may  take  because  there  is  always  present  a  deformity  or  change 
in  the  shape  of  the  bones.  The  nearest  likeness  to  it  is  in  the 


48  OSTEOPATHIC  MECHANICS 

rotation  of  the  vertebral  bodies  that  occurs  in  flexion-sidebending, 
namely,  to  the  convexity,  but  this  rotation  takes  place  without 
deformity. 

Scoliosis,  as  structural  curvature  is  preferably  called,  has  been 
for  convenience  divided  into  two  classes,  congenital  and  acquired. 
Under  the  heading  of  congenital  are  those  cases  which  may  be 
discovered  at  birth  or  shortly  afterward. 

Under  acquired  curvature  may  be  classified : 

A.  Curvatures  which  from  weakness,  bone  disease,  muscle 
atrophy,  became  structural  without  having  passed  through  the 
postural  stage. 

B.  Curvatures  which  at  first  belonged  to  the  functional  type, 
but  later,  from  neglect,  improper  treatment,  weakness  of  bone  or 
soft  tissues,  in  a  short  or  longer  process  of  time,  became  organic. 

The  reason  for  the  production  of  congenital  scoliosis  is  so 
evident  as  to  require  no  elaboration,  but  the  mechanism  of  change 
from  functional  to  structural  curvature  needs  demonstration. 

Weakness  and  weight  may  be  considered  the  two  greatest 
constant  factors  producing  deviations  from  the  normal  in  the 
curves  of  the  spinal  column.  Patients,  weak  from  disease  or 
fatigue,  show  frequently  the  influence  of  weight  in  the  accentua- 
tion of  the  normal  antero-posterior  curves;  the  increased  posterior 
thoracic  curve  being  spoken  of  as  a  kyphosis,  the  increased  anterior 
lumbar  curve  as  a  lordosis.  With  the  addition  of  faulty  posture, 
weight  and  fatigue  bring  about  lateral  spinal  curvature.  The 
process  between  this  and  scoliosis  may  be  explained  thus: 

Constant  weight  bearing  down  upon  the  upper  extremity  of 
a  flexible,  weight-bearing  arc,  would  cause  an  increase  in  the  curve 
of  that  arc,  a  decrease  in  its  radius.  But  when  that  arc  is  the 
human  spine,  it  is  not  a  mere  line.  It  is  composed  of  a  series  of 
solid  bodies,  held. together  by  soft  elastic  tissues,  rotating  on  an 
axis  passing  through  the  anterior  portion  of  each  body;  therefore, 
the  effect  of  weight,  after  the  compression  of  the  soft  tissues,  the 
intervertebral  discs  in  particular,  would  be  a  rotation  of  the  bones 
in  the  path  of  least  resistance,  or,  away  from  the  line  of  stress, 
toward  the  convexity  of  the  curve. 

In  functional  curvature  the  bodies  of  the  vertebrae  have 
rotated  to  the  concavity  of  the  curve;  in  structural  curvature,  they 


OSTEOPATHIC  MECHANICS 


49 


have  rotated  to  the  convexity  of  the  curve.  The  transverse 
processes  have  taken  part  in  the  revolution  of  the  vertebra  until 
in  scoliosis  upon  the  side  of  the  convexity  may  be  found  the  high 
side,  upon  the  concavity  the  low  side.  As  the  transition  from 
functional  to  structural  takes  place,  as  the  bodies  are  turning, 
there  comes  a  time  when  the  body  of  any  particular  vertebra  is 
directly  in  front,  antero-posteriorly,  of  the  spinous  process.  The 
vertebra  itself  shows  a  sidetilting  to  the  right  when  the  concavity 
is  on  the  right,  or  expressed  more  exactly,  a  line  erected  perpen- 
dicularly to  the  upper  surface  of  the  body  of  the  vertebra  would 


FIG.  11. — The  rotation  of  the  vertebra*  from  the  functional  stage  F  to  the  structural  stage 
S,  passes  through  the  intermediary  stages  Al,  A,  A2.  S.  P.  spinous  process;  L,  left  transverse 
process;  R,  right  transverse  process;  M-M,  antero-posterior  line  projected  from  the  axis  of 
rotation  of  each  vertebra  when  in  its  normal  position. 

project  upward  and  to  the  right.  At  this  place  in  the  rotation 
of  the  vertebra,  there  is  no  undue  prominence  of  either  transverse 
process,  so  that  it  is  impossible  to  distinguish  a  high  side  and  a 
low  side.  This  stage  of  curvature  may  be  named  the  transitional, 
a  stage  midway  between  functional  and  structural  wherein  there 
is  yet  no  change  in  the  shape  of  the  bones.  A  curvature,  as 
indicated  by  the  line  of  spinous  processes  exists  but  without  the 
other  differentiating  signs.  In  examining  a  patient  with  curvature, 
of  which  the  high  side  is  difficult  to  determine,  it  is  safe  to  suspect 
that  the  curvature  is  in  the  transitional  stage  and  that  the  bodies 
are  in  the  process  of  turning  toward  the  convexity.  The  prognosis 


50 


OSTEOPATHIC  MECHANICS 


OSTEOPATHIC  MECHANICS  51 

in  such  a  case  would  be  the  same  as  for  a  case  with  moderate 
scoliosis  except  in  one  class  of  cases,  those  with  flexible  spines  at  a 
time  when  the  vertebral  bodies  have  not  rotated  beyond  a  plane 
parallel  with  the  sagital  plane  of  the  body.  The  mechanical  prin- 
ciple in  the  treatment  of  such  a  case  would  be  to  turn  the  curva- 
ture back  to  the  functional  stage  while  building  up  the  general 
vitality  and  removing  the  cause,  and  then  correct  the  functional 
curve  by  the  usual  process. 

That  few  cases  are  found  in  the  transitional  stage  is  due  to 
the  fact  that  little  attention  is  paid  to  a  lack  of  symmetry  appear- 
ing in  the  growing  child  or  adolescent.  Much  is  left  to  chance  by 
parents  and  guardians.  It  has  been  the  popular  idea  that  children 
will  outgrow  defects  for  nature  will  overcome  every  ill,  over- 
looking the  fact  that  habit  is  ten  times  stronger  than  nature. 
School  boards  insist  upon  examining  a  child's  eyes,  ears,  nose, 
and  throat,  but  ask  no  privilege  in  regard  to  his  spine,  nor  even 
suggest  to  parents  the  advisability  of  consulting  a  physician  until 
the  case  with  an  easily  rectified  functional  curvature  has  progressed 
into  the  almost  incurable  stage  of  scoliosis. 

Total  functional  curves  most  frequently  change  to  total 
scolioses,  but  it  is  common  for  a  double  curve  to  be  formed  in  this 
change,  with  a  small  percentage  of  cases  changing  to  scolioses  of 
limited  extent,  oftenest  with  the  resulting  curve  in  the  dorsal  area. 

Following  the  transitional  stage  begins  true  scoliosis,  with  a 
change  in  the  shape  of  the  vertebrae,  due  to  the  fact  that  bone 
under  pressure  is  not  markedly  resistant.1  Bone  is  plastic,  a 
quality  which  as  Wolff  of  Berlin  has  shown,  causes  it  to  change  in 
response  to  functional  demands.  Wolff's  law  is  as  follows: 
"Every  change  in  the  formation  and  function  of  bones,  or  of  their 
function  alone,  is  followed  by  certain  definite  changes  in  their 
internal  structure  and  equally  definite  secondary  alterations  of 
their  external  conformation  in  accordance  with  mathematical  laws." 


1.  A  study  of  the  resistance  of  bone  and  of  the  soft  tissues  offers  some 
strange  deductions,  namely,  that  bone  is  less  resistant  than  is  generally  sup- 
posed and  soft  tissues  more  resistant.  There  seems  no  limit  to  the  amount 
of  deformity  possible  in  any  particular  bone  while  on  the  other  hand  the 
resistance  of  soft  tissues  may  set  a  limit  to  the  extent  of  the  osseous  deformity 
and  contrariwise  often  is  the  means  by  which  it  is  perpetuated  as  for  example 
adaptive  shortening  or  contracture  of  muscles  on  the  concavity  of  a  lateral 
spinal  curvature. 


52 


OSTEOPATH ic  MECHANICS 


FIG.   13. — Scoliotic  spine.     (J.  S.  K.  Smith). 


OSTEOPATHIC  MECHANICS  53 

Following  this  rule  of  plasticity  Wolff1  further  explains:  "Ac- 
cording to  this  reasoning,  deformities  are  nothing  less  than  the 
result  of  the  transformations  which  the  external  form  of  bones  or 
joints  undergoes  in  accommodating  itself  to  faulty  demands.  It 
must  be  self-evident  that  that  which  is  pathological  is  only  the 
altered  static  requirement,  the  abnormal  mechanical  function. 
Far  from  being  really  pathological  the  deformity  is  the  only  suit- 
able or  even  possible  form  by  means  of  which  bone  or  joint  can 
withstand  the  altered  forces  bearing  upon  it;  it  is  nature's  way  of 
securing  the  greatest  possible  service  and  strength  under  new 
conditions  with  the  use  of  the  least  possible  amount  of  material. 

"In  the  absence  of  an  abnormal  softness  of  bone,  the  body  of 
a  vertebra  may  lose  height  on  the  concave  side  and  gain  the  same 
on  the  convex  side  through  the  'tropic  stimulus  of  function'  purely; 
being  simply  an  accommodation  to  the  diminished  space  on  the 
concave  side  and  increased  room  at  the  convexity  and  the  change 
of  mechanical  conditions  consequent  thereupon."2 

The  pathological  effects  occuring  in  scoliosis  vary  in  degree 
from  mere  asymmetry  to  marked  distortion.  The  first  effect 
comes  in  the  vertebra  themselves.  At  the  apex  of  the  curve 
the  bodies  of  the  vertebrae  become  wedge-shaped,  with  the  base 
of  the  wedge  between  the  lateral  and  ventral  surfaces  of  the  body 
on  the  concavity  of  the  curve ;  with  the  apex  of  the  wedge  between 
the  posterior  and  lateral  surfaces  of  the  body  on  the  convexity 
of  the  curve.  The  spinous  processes  in  the  lumbar  region  are 
deflected  toward  the  concavity;  in  the  dorsal  area  while  turned 
toward  the  concavity,  they  tend  to  be  deflected  at  the  tip  down- 
ward and  toward  the  convexity.  The  vertebra  between  the 
apices  of  the  curves  and  the  normal  part  are  oblique  in  character, 
the  upper  and  lower  surfaces  sliding  upon  each  other.  Due  to 
the  crowding  together  of  the  articular  processes  on  the  side  of 
the  concavity,  there  is  an  increase  in  their  size,  while  on  the  con- 
vexity from  the  separation  of  the  pedicles,  they  are  smaller  and 
higher.  In  many  specimens,  synostoses  are  found  between  the 
joints  on  the  concavity  with  some  ossification  of  their  ligaments. 

1.  Die    Lehre   von    der   functionellen    Pathogenese   der    Deformitseten, 
Archiv.  fur  klinische  Chirurgie,  Bd.  liii.,  H.  4. 

2.  Translation    more   complete   in   Whitman's    "Orthopedic   Surgery," 
4th  Edit.,  page  242. 


54 


OSTEOPATHIC  MECHANICS 


The  ligamentous  changes  correspond  to  the  osseous  changes. 
On  the  side  of  the  concavity  the  anterior  longitudinal  and  lateral 
spinal  ligaments  are  thicker  and  shorter  than  in  the  normal 
flexible  spine.  On  the  convexity  they  are  thinned,  longer,  and 
somewhat  atrophied. 

Muscular  changes  are  easily  palpated.  Because  of  the  rigidit  y 
which  comes  early  in  cases  of  scoliosis,  there  is  a  general  atrophy 


FIG.  14. — Shape  and  position  of  the  ribs  of  the  normal  spine  (F:<r.  I.),  of  the  spine  in  func- 
tional curvature  (Fig.  II),  and  of  the  scoliotic  spine. 


OSTEOPATHIC  MECHANICS 


55 


of  the  muscles  of  the  back  from  lack  of  use.  On  the  concave  side 
a  fibrous  degeneration  is  a  frequent  condition ;  on  the  convex  side 
there  is  a  thinning  and  wasting  of  muscle  tissue. 

Severe  cases  are  characterized  by  great  deformities  in  other 
osseous  Structures  beside  the  spine.  Some  of  these  changes  are 
marked,  especially  in  the  ribs,  which  by  the  influence  of  the  rota- 
tion of  the  vertebral  bodies  and  the  longitudinal  tension  of  the 

spinal  muscles,  are  not  only 
||  changed  in  their  relation 
to  other  bones,  but  show 
structural  changes  in  angu- 
larity, which  on  the  side  of 
the  convexity  shows  a  mark- 
ed increase,  throwing  the 
scapula  backward  so  that  it 
often  appears  to  be  larger 
than  its  fellow;  from  the 
angle  forward  to  their  costal 
extremities  these  ribs  have 
less  than  the  normal  curve, 
are  much  more  oblique,  and 
are  spread  farther  apart.  On 
the  concavity  the  angles 
are  straightened,  the  shafts 
present  an  increased  curve, 
are  more  horizontal,  and 
closer  together.  The  scap- 
ula on  the  concavity  lies 
close  to  the  thorax. 

The  sternum  and  clavicle 
show  slight  changes  in  con- 
formation. The  pelvis  in 
its  deformities  is  like  the 
thorax  but  much  less  in 
degree. 

The   appearance   of    the 
patient   with   a    structural 
FIG.  i5.-scoiiosis.    (Laughiin).  curvature   varies   with   the 


56 


OSTEOPATHIC  MECHANICS 


intensity  of  the  curve, 
and  with  the  area  involv- 
ed. Lumbar  scolioses  are 
characterized  by  less  de- 
formity than  presented  by 
other  areas.  The  appar- 
ently larger  hip  and  the 
depth  of  waist-line  on  the 
concave  side  and  the  dis- 
placement of  the  trunk  to 
the  convexity  are  the  prin- 
ciple signs  of  the  lumbar 
curvature.  Diagnosis  rests 
upon  the  presence  of  the 
high  side  upon  the  con- 
vexity. The  patient  in 
bending  over  loses  none  of 
the  appearance  of  curva- 
ture, and  the  high  side  per- 
sists upon  the  convexity. 
It  must  not  be  forgotten 
that  lumbar  rotation  is  less 
than  dorsal  rotation,  being 
always  secondary  to  side- 
bending,  therefore  curva- 
tures which  might  appear 
to  be  slight  in  that  region 
may  in  reality  be  severe. 

A  case  of  total  scoliosis  has  the  same  signs  as  a  lumbar  curve, 
with  the  additional  sign  of  the  high  shoulder  on  the  convexity 
and  changes  in  the  lower  ribs.  Dorsal  scoliosis  presents  the  most 
marked  deformities.  A  patient  with  a  dorsal  scoliosis  convex  to 
the  left  presents  this  picture:  the  thorax  as  a  whole  is  displaced 
to  the  left;  the  left  arm  hangs  farther  from  the  side  than  the  right 
arm;  the  waist-line  on  the  left  is  flattened,  on  the  right  deeper; 
the  contour  of  the  chest  is  changed  anteriorly  and  the  longest 
diameter  is  an  oblique  antero-posterior  line  from  the  left  scapula 
to  the  right  nipple.  The  line  of  spinous  processes  is  no  guide  to 


FIG.   16. — -Incurable  Scoliosis.     (Laughlin). 


OSTEOPATHIC  MECHANICS 


57 


FIG.  17. — Scoliosis,  right  dorsal 
primary,  left  lumbar  secondary. 
(Laughlin). 


FIG.  18. — Same  patient  in  flexion, 
showing  high  side  on  the  convexity. 
(Laughlin) . 


the  amount  of  rotation  present  in  the  vertebral  bodies  for  the 
bodies  in  structural  curvature  move  farther  from  the  sagital  plane 
than  the  spines. 

Compound  structural  curvatures  combine  the  features  of  the 
simple  scolioses.  They  are  more  frequent  than  any  other  class, 
occurring  in  thirty  percent  of  all  cases.  Scolioses  may  change 


FIG.   19. — Lumbar  scoliosis,  showing  high  side  on  the  convexity. 


58  OSTEOPATHIC  MECHANICS 

from  one  clinical  type  to  another  in  the  course  of  years.  Total 
curves  change  to  compound  curves  oftenest,  and  compensatory 
curves  follow  all  types.  Schulthess  tabulated  over  one  thousand 
cases  in  the  order  of  their  coming  for  treatment  and  found  the 
relative  frequency  of  certain  types  as  follows: 

Compound  scoliosis . . . 

30  percent 

Dorsolumbar .  .20      " 

Dorsal 19      " 

Total 15      " 

Lumbar 11      " 

Cervicodorsal .  3      " 

The  patients  who  have 
scoliosis  do  not  manifest 
any  symptoms  directly 
resulting  from  the  con- 
dition unless  the  case 
belongs  to  the  severe 
type  when  pain  is  often 
complained  of  and  is 
probably  due  to  strain 
from  altered  muscular  or 
ligamentous  tension, 
pressure  from  distorted 
ribs  upon  nerve  fibres,  or 
as  a  neurasthenic  symp- 
tom of  lowered  vitality 
and  decreased  resistance 
to  ordinary  irritations. 

In  consequence  of  the 
alteration  in  the  shape  of 
the  thorax  there  are  no- 
.  ticeable  pressure  effects 
upon  the  viscera  with 
pathological  conditions 
following.  The  chest 

FIG.  20.— Left    dorsal    scoliosis    from    anterior  rliamG-fov     rm    tVif>    r»nnvr>v 

poliomyelitis.     (Laughlin.) 


OSTEOPATHIC  MECHANICS 


59 


FIG.  21. — Same  patient  as  Fig.  20.     Scoliosis  corrected  with  two  casts,  during  six  months 
of  treatment.     (Laughlin). 

side  is  much  reduced  and  in  consequence  there  is  less  lung  capacity. 
Anemia  may  be  a  secondary  effect.  The  heart  may  suffer  dis- 
placement. Venous  dilatation  and  cardiac  hypertrophy  may  be 
found  due  to  the  difficulty  with  which  the  heart  pumps  the  blood 
through  the  lungs  in  the  effort  to  aerate  it. 

The  abdominal  contents  on  account  of  the  restriction  of  space 
suffer  from  the  crowding  and  displacement.  Diseases  in  the  liver, 
kidneys,  spleen,  intestines,  and  stomach,  in  patients  of  the  scoliotic 
type,  are  undoubtedly  due  to  spinal  conditions  and  thoracic 
deformities. 

TREATMENT 

The  problem  presented  by  any  case  of  structural  curvature 
is  the  overcoming  of  bone  deformity  and  as  such  belongs  properly 


60 


OSTEOPATHIC  MECHANICS 


FIG.  22. — The  Abbott  frame  in  position  for  application  of  a  cast  in  a  case  of  right  thoracic 
scoliosis.     (Laughlin.) 

to  orthopedic  surgery.  For  four  thousand  years  scoliosis  has  been 
regarded  as  a  muscle  problem  and  in  consequence  the  history  of 
its  treatment  is  largely  one  of  failure. 

The  first  logically  sound  solution  of  the  problem  was  offered 
by  the  recent  studies  of  Lovett  and  others  into  the  mechanics 
of  the  spine.  Sidebending  and  rotation  had  not  been  understood 
and  until  the  principle  of  these  movements  was  discovered  and 
applied  to  the  treatment  of  curvature,  advance  was  impossible. 

Less  than  a  decade  ago  a  Portland  orthopedist,  E.  C.  Abbott, 
offered  the  first  truly  mechanical  foundation  for  correction  of  the 
deviation.  Its  principle  is  physiological  production  of  sidebending- 
rotation  in  a  position  which  shall  carry  the  bodies  of  the  vertebrae 
to  the  convexity  and  to  maintain  them  in  this  position  until  the 
bones  shall  have  changed  their  shape  back  toward  the  normal. 

The  process  of  application  is  as  follows : 

I.  The  position  of  flexion. — The  patient  lies  in  a  hammock 
or  canvas  sling  which  hangs  in  a  gas-pipe  frame.  (Fig.  22.)  The 


OSTEOPATHIC  MECHANICS 


61 


hammock  is  cut  on  the  bias  so  that  beneath  the  shoulder  on  the 
concavity  there  shall  be  more  room. 

II.  The  pelvis  is  fixed  by  straps  fastened  to  a  lateral  arm  of 
the  frame,  on  the  side  of  the  convexity.  A  similar  strap  pulls 
up  the  low  shoulder,  to  stretch  the  concavity  and  raise  the  shoulder. 
A  strap  is  put  around  the  thorax  at  the  convexity  of  the  curvature 
and  fastened  to  a  lateral  arm  of  the  frame  on  the  side  of  the  con- 
cavity so  that  it  can  be  pulled  laterally  until  sidebending  has  been 
given  the  convexity. 


FIG.  23. — The  deformity  of  the  thorax  in  scoliosis.  The  holes  which  should  be  cut  in  the 
cast  and  the  location  for  extra  pressure  by  felt  pads  are  indicated.  The  arrows  show  the  direc- 
tions of  the  various  force?.  (Laughlin.) 


62 


OSTEOPATHIC  MECHA.MI  > 


III.  Immobilization  is  now  made  by  the  application  of  a 
plaster  of  Paris  cast. 

IV.  To  assist  in  the  rotation  of  the  vertebrae,  pressure  is 
applied  over  the  angles  of  the  ribs  on  the  convexity  with  reinforce- 
ment   diagonally  across  on   the  ventral  surface  by  the  insertion 
of  pads  from  time  to  time.     Over  the  angles  of  the  ribs  on  the 
concavity  and  diagonally  across  in  front  openings  are  made  in  the 
cast  so  that  respiration  may  cause  the  ribs  to  bulge  and  regain 
their  normal  shape. 

V.  Over-correction  is  the  last  step  for  it  is  necessary  to  make 
permanent  the  changes  wrought  by  the  application  of  the  casts. 
It  is  maintained  until  the  thorax  returns  to  its  normal  contour. 
Following  the  removal  of  the  last  plaster  cast,  the  patient  is  placed 
for  a  time  during  waking  hours  in  a  celluloid  or  leather  jacket,  so 
that  an  opportunity  for  acquiring  strength  may  be  given  the 
muscles  wasted  by  the  pressure  of  the  cast  and  from  disuse. 

The  class  of  patients  who  are  cured  by  the  Abbott  cast  are 
principally  those  with  the  simple  forms  of  scoliosis  or,  better,  the 
long  total  or  dorsal  types.  Very  few  double  scolioses  are  bene- 


FIQ.  24. — "The  rotation  of  the  body  of  the  vertebra  to  the  right  in  a  right  dorsai 
scol:osis.  Pressure  at  the  point  C  is  responsible  for  the  rotation  of  the  body  of  the  vertebra  to 
the  right  through  the  attachment  of  the  rib  at  the  points  a  and  b.  If  the  maximum  of  pres- 
sure in  correction  is  exerted  at  B,  it  will  be  felt  at  the  point  b  and  will  tend  to  reduce  the 
rotation."  (Laughlin.) 


OSTEOPATHIC  MECHANICS  63 

fitted.  Casts  in  these  cases  are  applied  for  what  seems  to  have 
been  the  primary  curve;  after  its  correction  the  compensatory 
or  secondary  curve  would  naturally  disappear;  if  it  did  not, 
after  time  had  been  given  for  the  secondary  curve  to  be  determined 
as  to  its  permanent  character,  it  should  receive  appropriate 
t  reatment. 

The  patients  must  be  well-nourished  children  or  young 
adults.  Frail  children  or  very  young  children  are  not  suitable 
patients  for  confinement  in  plaster  casts.  In  the  very  young,  it 
is  sometimes  possible  with  the  changes  incident  to  growing  bone 
to  accomplish  correction  by  leather  jackets  or  other  appliances. 

Those  patients  who  have  marked  dorsal  kyphoses  with  lateral 
deformitiy  are  not  much  helped  for  the  reason  that  when  the 
vertebrae  are  immobilized  in  flexion,  there  is  already  all  the  forward 
bending  the  vertebra  will  stand,  and  without  flexion  beyond 
that  held  in  the  curvature,  the  articular  processes  could  not  be 
"unlocked,"  nor  the  tension  of  the  intervertebral  discs  changed, 
both  of  which  are  essential  to  correction  of  vertebral  lesions  singly 
or  in  groups. 

Osteopathic  treatment,  aside  from  that  outlined  above,  given 
by  the  orthopedic  specialists  of  our  school  of  practice,  should  be 
given  before  the  cast  operation  and  after  it.  It  should  be  in  the 
nature  of  a  general  treatment,  which  the  author  holds  is  putting 
the  spinal  joints  through  their  normal  movements  as  far  as  possible. 
Flexibility  is  indispensable  to  the  early  correction  of  scoliosis  by 
cast.  Movements  of  flexion  and  extension  and  torsion  away  from 
the  convexity,  are  indicated. 

Following  the  removal  of  the  plaster  cast,  and  while  the  patient 
is  wearing  the  celluloid  one,  treatment  should  be  given  for  the 
upbuilding  of  muscle  strength  and  increased  vitality  of  the  patient. 
As  soon  as  the  jackets  are  left  off,  the  patient  should  be  given  exer- 
cises strictly  under  the  direction  of  the  physician  for  the  develop- 
ment of  muscular  strength  throughout  the  body.  The  same 
movements  that  have  been  before  recommended  in  the  after- 
treatment  of  functional  curvature  may  be  given.  In  addition 
special  attention  should  be  given  to  the  leg  and  thigh  muscles  so 
that  the  patient  may  be  able  to  stand  and  walk  without  fatigue; 
to  the  chest-expanding  muscles  to  increase  respiratory  capacity; 


64  OSTEOPATHIC  MECHANICS 

to  the  muscles  of  vertebroscapular  attachment  so  that  the  shoulder 
girdles  may  be  supported  with  comfort;  to  the  abdominal  and 
spinal  muscles  to  strengthen  the  spine,  and  to  the  cervical  area 
for  the  easy  carriage  of  the  head.  The  field  is  a  large  one  for  the 
osteopathist.  He  best  of  all  classes  of  physicians  is  fitted  for  this 
work. 

The  detail  of  the  Abbott  method  has  not  been  given.  The 
reader  is  referred  to  the  excellent  monograph  of  Dr.  George  M. 
Laughlin,  reprinted  from  the  "Journal  of  Osteopathy, "  for  March, 
1914,  for  the  technique  of  this  method  and  the  results  obtained. 

In  regard  to  the  treatment  that  has  been  accorded  these  cases 
by  the  gymnastic  method,  it  seems  advisable  to  state  that  the 
dangers  are  greater  than  any  possible  good  that  could  be  derived 
therefrom.  Robert  W.  Lovett1  has  covered  this  point  well,  as 
follows : 

"Not  only  may  gymnastics  in  moderate  and  severe  struct ural 
scoliosis  fail  to  do  good,  but  they  frequently  do  serious  harm  for 
the  following  reason :  scoliosis  of  this  grade  soon  results  in  a  stiff- 
ening of  the  affected  region  of  the  spine.  If  efficient  gymnastics 
are  given,  the  spine  is  speedily  rendered  more  flexible  and  if  it  is 
so  rendered  and  not  supported  at  once  it  will  sink  into  a  worse 
position  than  before  and  the  curve  will  be  increased. " 

1.  Lovett,  ibid,  page  127,  second  paragraph. 


OSTEOPATHIC  MECHANICS  65 

CHAPTER  IV. 
FLEXION  AND  EXTENSION  LESIONS 

FLEXION   LESIONS 

A  flexion  lesion  is  a  subluxation,  or  an  immobilization,  of  a 
vertebral  articulation  in  the  position  of  flexion. 

It  is  not  abnormal  for  any  spinal  joint  at  some  period  in  the 
life  of  the  individual  to  assume  the  position  characteristic  of  a 
flexion  lesion,  but  it  is  abnormal  at  any  time  for  that  joint  to 
become  immobilized  in  flexion.  Immobilization  may  be  defined 
as  fixation  and  differs  from  the  static  position  of  rest  in  the  path- 
ological changes  that  have  taken  place  in  the  supporting  and 
surrounding  tissues  and  also  in  the  fact  that  it  is  mechanically 
inert.  Its  restoration  to  function  depends  upon  the  overcoming 
of  physiological  reactions  and  pathological  restrictions.  Occasion- 
ally these  readjustments  are  spontaneous. 

From  the  study  of  the  normal  movement  of  flexion,  the  ana- 
tomical relations  present  in  lesion  may  be  deduced : 

Spinous  process. — Separated  from  the  one  below,  approxi- 
mated to  the  one  above. 

Facets. — Parts  of  the  articular  surfaces  in  apposition. 

Body. — Slightly  anterior  at  the  anterior  inferior  margin. 

Disc. — Compresssed  anteriorly  and  stretched  somewhat  pos- 
teriorly. 

Ligaments. 

I.  Stretched,  thinned,  and  atrophied 

a.  Posterior  longitudinal. 

b.  Flava. 

c.  Supraspinous. 

d.  Interspionous. 

e.  Intertransverse. 

II.  Relaxed  and  thickened 

a.  Anterior  longitudinal. 

Intervertebral  foramina. — Increased  in  size  above,  decreased 
below.1 


1.  The  separation  of  the  pedicles  of  the  vertebra  in  lesion  and  of  the  one 
below  is  meant.  In  fact,  the  foramina  are  ultimately  decreased  in  size  by  the 
deposition  of  connective  tissue,  the  result  of  the  inflammatory  changes  that 
take  place  while  the  lesion  is  in  the  acute  stage. 


66 


OSTEOPATHIC  MECHANICS 


Muscles. — Fasciculi  of  the  extensor  muscules  of  that  area 
stretched  and  atrophied;  corresponding  muscles  of  flexion  con- 
tracted. 

The  determination  of  a  flexion  lesion  is  made  by  palpation.1 
In  the  early  literature  of  osteopathy  the  flexion  lesion  was  called 
posterior,  for  the  reason  that  the  spinous  process  of  the  vertebra 
in  lesion  appears  more  prominent  than  adjacent  ones.  The 
reason  for  this  prominence  is  due  to  the  separation  of  its  tip  from 


FIG.  25. — The  appearance  of  the  spinous  processes  when  a  flexion  lesion  is  present  in  the 
second-third  thoracic  articulation. 


1.  It  should  be  required  of  every  patient  coming  for  examination  that  he 
bare  his  spine  for  inspection  and  palpation.  In  no  other  way  can  an  accurate 
diagnosis  be  made. 


OSTEOPATHIC  MECHANICS  67 

that  of  the  spinous  process  below,  throwing  the  upper  of  the  two 
into  relief  in  the  plane  of  the  back.  In  the  examination  of  a  patient 
prominences  should  be  noted  and  careful  palpation  made  to  deter- 
mine whether  or  not  they  are  indicative  of  flexion  lesions.  A 
spinous  process  may  be  posterior  in  relation  to  the  general  line  of 
spinous  processes  and  yet  not  be  the  sign  of  a  flexion  lesion.  Such 
processes  are  usually  anomalous  conditions,  the  spinous  process 
being  longer  than  its  fellows  and  longer  than  that  of  the  normal 
vertebra.  THE  PROOF  OF  LESION  is  LOSS  OF  FUNCTION,  RESTRICTED 
MOTION. 

EXPERIMENTAL  PALPATION,  A. — Ask  the  patient,  B,  to  sit 
upon  a  stool,  while  O  stands  beside  him.  B's  spine  should  be 
bare.1  Let  O  pass  his  fingers  down  the  row  of  upper  thoracic 
spinous  processes  until  he  finds  the  one  which  seems  more  prom- 
inent than  the  others.  Let  us  assume  that  it  is  the  sixth  thoracic. 
Let  O  place  the  ball  of  his  forefinger  between  the  fifth  and  sixth 
spinous  processes  and  the  ball  of  the  second  finger  between  the 
sixth  and  seventh.  0  should  compare  the  distance  between  these 
spinous  processes.  If  the  sixth  is  in  flexion  lesion,  its  spine  will 
be  farther  from  the  seventh  than  from  the  fifth.  Let  O  compare 
also  the  distance  between  adjacent  spinous  processes  above  and 
below. 

Let  O  place  his  other  hand  upon  B's  head  and  move  it  forward 
strongly.  In  the  normal  spine,  or  the  spine  having  a  sixth  thoracic 
vertebra  with  a  long  process,  there  will  be  increased  separation 
between  the  spinous  processes,  and  the  movement  in  separation 

1.  Osteopathic  diagnosis  rests  largely  upon  the  difficult  art  of  palpation. 
It  is  that  part  of  the  student's  preparation  which  should  be  emphasized  from 
the  outset.  Since  people  vary  physically  to  the  degree  that  one  may  say 
when  the  problem  under  consideration  is  technique,  that  every  human  being 
is  a  law  unto  himself,  it  may  be  best  to  outline  what  I  think  should  be  the 
course  of  private  study  for  each  student  who  is  beginning  this  work. 

The  spine  of  the  living  model  is  indispensable  to  the  student.  He  should 
select  at  first  a  model  who  is  about  twenty  years  of  age,  in  good  health,  and  as 
far  as  possible  one  who  has  no  lesions.  By  placing  the  balls  of  his  fingers 
between  every  two  spinous  processes,  he  may  palpate  the  change  in  their 
relations  while  the  subject  makes  the  normal  movements  of  the  spine.  As 
soon  as  the  student  feels  that  he  has  acquired  the  ability  to  detect  movement 
in  the  spinal  articulations  of  the  various  areas  in  this  subject,  he  should  select 
models  who  have  spines  less  easily  palpated,  as  those  who  are  old,  prematurely 
rigid,  obese,  over-muscular,  and  hypermobile.  With  the  advance  in  the  work, 
while  he  is  studying  lesions,  he  should  ask  the  privilege  of  examining  the 
spines  of  as  many  people  as  would  be  interested  in  assisting  him  to  cultivate 
his  sense  of  touch.  C.  P.  McConnell  says  "Educated  fingers  do  not  come  by 
chance  but  only  by  the  hardest  kind  of  labor  and  effort."  He  thinks  also 
that  six  to  nine  months  are  necessary  for  this  foundation.  See  "The  Journal 
of  the  A.  O.  A."  for  March,  1913,  page  417. 


68 


OSTEOPATHIC  MECHANICS 


FIG.  26. — Manner  of  palpating  for  flexion  and  extension  lesions  of  the  thoracic  area. 
The  hand  upon  the  head  uses  it  as  a  lever  to  produce  movement  in  the  thoracic  region.  The 
thumb  between  the  spinous  processes  determines  the  presence  or  absence  of  motion. 


OSTEOPATHIC  MECHANICS 


69 


will  be  easily  detected.  If  a  flexion  lesion  is  present,  there  will 
be  no  change  in  the  separation  of  the  sixth  and  seventh.  Let  O 
then  carry  B's  head  backward  strongly  in  extension,  whereupon 
if  lesion  is  not  present,  the  spinous  process  of  the  sixth  will  approxi- 
mate that  of  the  seventh.  If  the  sixth  is  in  flexion  lesion,  there 
will  be  no  change  in  the  relative  distance  between  the  spinous 
processes. 

From  the  above  experimental  palpation,  the  terms  of  the 
diagnosis  of  a  flexion  lesion  may  be  stated: 

THE  SPINOUS  PROCESS  OF  A  VERTEBRA  IN  FLEXION  LESION  is 

SEPARATED  FROM  THE  SPINOUS  PROCESS  OF  THE  VERTEBRA  BELOW 
AND  ANY  MOVEMENT  OF  THAT  AREA  OF  THE  SPINE  DOES  NOT  CHANGE 
THE  AMOUNT  OF  SEPARATION  BETWEEN  THE  TWO  PROCESSES. 

EXPERIMENTAL  PALPATION,  B. — Since  flexion  lesions  of  the 
lumbar  area  are  sometimes  difficult  to  diagnose  with  the  patient 
seated  upon  a  stool,  let  the  patient,  B,  who  is  supposed  to  have  a 
flexion  lesion  of  the  fourth  lumbar  vertebra,  lie  upon  his  left  side 
upon  the  operating  table,  facing  0  who  stands  beside  the  table. 
O  flexes  B's  knees  and  places  them  against  O's  abdomen,  while 
he  holds  B  firmly  upon  the  table  by  placing  his  right  hand  over 
the  dorsolumbar  area  of  his  back.  0  places  the  finger  tips  of 
his  left  hand  along  the  spinous  processes  of  B's  lumbar  area  with 
the  purpose  of  finding  the  prominent  fourth  lumbar  spinous 
process  and  of  comparing  the  distance  between  it  and  the  adjacent 
spinous  processes.  If  the  fourth  is  in  flexion  lesion,  its  spinous 


FIG.  27.— Manner  of  palpating  for  the  detection  of  flexion  and  extension  lesions  of  the 
lumbar  area. 


70 


OSTEOPATHIC  MECHANICS 


process  would  be  farther  from  the  fifth  than  from  the  third.  By 
shifting  his  weight  from  one  foot  to  the  other,  at  the  same  time 
maintaining  firm  pressure  with  his  right  hand  upon  B's  spine,  O 
may  produce  flexion  and  extension  in  B's  lumbar  area  and  detect 
the  presence  or  absence  of  motion  in  those  joints.  If  the  pal- 
pating finger  finds  separation  and  restricted  motion  in  the  fourth- 
fifth  interspace,  then  the  diagnosis  of  flexion  lesion  is  confirmed. 

:  Differential      diagnosis 

will  substantiate  prelimi- 
nary diagnosis  and  should 
be  a  part  of  every  routine 
examination.  Flexion 
lesions  are  to  be  differen- 
tiated from 

1.  Extension  lesion  of  the 
vertebra  below  by  restrict- 
ed motion  in  the  interspace 
where  there  is  separation 
of  spinous   processes    and 
free  motion  in  the  inter- 
space where   there   is    an 
approximation  of  spinous 
processes. 

2.  The  anomalous  con- 
dition of  a  fourth  lumbar 
vertebra1  with  a  long  spin- 
ous process  which  would 
be    determined     by    the 
presence  of  movement  in 
the  third-fourth  and 
fourth-fifth  joints. 

3.  The  anomalous  con- 
dition of  a  short  spinous 
process  of  an  adjacent  ver- 
tebra  determined   by  the 
presence  of  motion  in  the 
joints  above  and  below. 

Flexion  lesions  are  most  commonly  the  result  of  strain.  An 
individual  bending  forward  in  as  much  flexion  as  his  spine  will 
permit,  is  acted  upon  by  a  superior  force  with  the  result  that  one 

1.  The  spinous  process  of  the  fourth  lumbar  vertebra  is  frequently  longer 
than  normal,  while  the  fifth  lumbar  has  normally  the  shortest  spinous 
process  among  the  lumbars.  The  third  is  mentioned  by  some  writers  as  the 
one  having  the  thickest  spinous  process. 


FIG.  28. — Schematic  drawing  to  illustrate  the 
separation  of  spinous  processes  in  the  case  of  a 
flexion  lesion  of  the  third-fourth  lumbar  articula- 
tion. The  larger  size  of  the  circle,  indicating  the 
spinous  process  of  the  third,  represents  its  promi- 
nence as  seen  when  looking  at  the  back.  In  the 
interspace  R,  motion  is  found  restricted. 


OSTEOPATHIC  MECHANICS  71 

or  more  of  the  spinal  articulations  are  forced  into  greater  flexion, 
in  reality  into  subluxation,  wherein  the  articulating  surfaces 
remain  but  slightly  apposed.  Upon  resuming  the  upright  posi- 
tion, all  of  the  spinal  joints,  save  those  injured,  return  to  the 
normal.  Examination  of  the  lesioned  articulations  would  reveal 
the  fact  that  ligaments,  whose  purpose  has  been  not  only  to  con- 
nect bones  but  to  limit  motion  in  the  joint,  have  been  unduly 
stretched  and  will  quickly  show  the  effects  of  injury,  congestion 
and  subsequently  atrophy,  thinning,  and  sometimes  calcareous 
deposit. 

Strain  usually  occurs  suddenly  and  unexpectedly,  by  accident, 
blows,  falls,  or  the  lifting  of  heavy  weights.  Certain  areas  are 
prone  to  these  lesions,  especially  the  cervicodorsal  and  dorsolumbar 
junctions  due  to  the  restricted  mobility  of  the  thoracic  region, 
and  the  greater  freedom  of  motion  in  the  cervical  and  lumbar 
areas.  The  lumbar  region1  is  also  liable  to  these  lesions  because 
upon  that  area  of  the  spine  rests  the  greatest  amount  of  super- 
incumbent weight. 

Sometimes  by  gradual  production  are  flexion  lesions  formed. 
Muscular  insufficiency  is  the  source  of  the  final  result.  The  first 
cause  may  be  infection,  toxin,  or  any  one  of  many  agencies  setting 
up  an  irritation  in  or  about  the  joint,  from  which  the  individual 
seeks  relief  by  carrying  the  spine  uneasily  in  flexion.  The  fasci- 
culi of  the  extensor  muscles  are  stretched  and  unbalance  is  present. 
The  flexors  hold  what  they  have  gained  and  in  time  the  same 
amount  of  change  has  taken  place  in  the  spinal  joint  that  might 
have  been  occasioned  by  a  sudden  expenditure  of  force.  Injuries 
to  the  muscle  mass  of  any  of  the  extensors  or  weakness  from  other 
cause,  or  irritations  causing  contractions  of  flexors,  would  act  in 
the  same  manner  to  assist  in  the  production  of  a  flexion  lesion. 
Group  lesions  are  always  of  gradual  production. 

CORRECTIVE  MOVEMENTS 
THE   PRINCIPLE   OF   CORRECTION   FOR   FLEXION  LESIONS  is 

EXTENSION. 


1.  Flexion  lumbar  lesions  are  etiologic  in  causing  pelvic,  bladder,  and 
rectal  disorders.  Constipation  of  the  large  intestine  may  often  be  traced 
directly  to  such  a  lesion  and  leucorrhea  is  a  common  symptom  of  a  fifth 
lumbar  flexion  lesion. 


72  OSTEOPATH ic  MECHANICS 

GENERAL  RULES. — THE  ARTICULATING  SURFACES  MUST  RE- 
TRACE THE  PATH  THEY  TOOK  IN  THEIR  DISPLACEMENT.  It  has  been 

well  said  that  it  requires  but  a  little  force  at  exactly  the  right  angle 
to  produce  a  lesion  and  conversely  that  a  little  force  applied  in 
exactly  the  right  direction  will  reduce  a  subluxation.1 

There  are  two  methods  commonly  employed  by  osteopathists 
in  the  correction  of  lesions  the  older  of  which  is  the  traction  method. 
the  later  the  direct  method  or  thrust.2  Those  who  employ  the 
traction  method  secure  the  relaxation  of  the  tissues  about  the 
articulation  by  what  has  been  termed  exaggeration  of  the  lesion, 
a  motion  in  the  direction  of  the  forcible  movement  which  produced 
the  lesion,  as  if  its  purpose  were  to  increase  the  deformity.  C.  P. 
McConnell  states  that  this  disengages  the  tissues  that  are  holding 
the  parts  in  the  abnormal  position.  It  is  more  than  probable 
that  the  effectiveness  of  this  procedure  is  due  to  the  physiological 
reaction  that  is  set  up  in  those  tissues  which  have  the  power  of 
contractility,  the  flava  ligaments  and  the  extensor  muscle  fasci- 
culi in  the  case  of  the  lesions  under  discussion.  The  exaggeration 
is  held,  traction  made  upon  the  joint,  replacement  initiated  and 
then  completed  by  reversal  of  the  forces.3 

The  direct  method  consists  in  the  application  of  a  precisely 
directed  force  toward  a  bony  prominence  during  the  process  of 
putting  the  articulation  in  lesion  through  the  spinal  movement 
which  is  the  reversal  of  that  which  produced  the  lesion.  Relaxa- 
tion of  restraining  tissues  is  secured  by  the  corrective  movements 
preliminary  to  adjustment.  It  avoids  the  expenditure  of  force 
often  essential  to  the  successful  use  of  traction. 

1.  CHIN-RAISING  MOVEMENT. — A  patient,  B,  is  assumed  to 
have  a  flexion  lesion  of  the  second  thoracic.  Let  the  patient  sit 
upon  a  stool  while  O  stands  at  his  left  side.  O  places  B's  chin  in  the 
bend  of  his  elbow,  passing  the  forearm  up  beside  B's  cheek  and  rest- 
ing the  hand  lightly  on  his  head.  O  places  the  hypothenar  eminence 
of  his  right  hand  against  the  spinous  process  of  the  second  thoracic 
vertebra,  the  palm  of  the  hand  resting  against  the  back  of  B's 


1.  Statement  of  Dr.  Ethel  Louise  Burner.  Bloomington,  111. 

2.  The  term  "direct"  is  preferred  for  the  reason  that  the  imitators  of 
osteopathy  have  given  to  the  word  "thrust"  an  objectionable  meaning  of 
harshness. 

3.  This  method  is  the  more  difficult  of  the  two  and  for  the  instruction  of 
students  does  not  find  favor  with  the  author. 


OSTEOPATHIC  MECHANICS 


73 


FIG.  29. — Illustrating  the  chin-raising  movement. 

neck,  the  thumb  and  forefinger  spread  below  B's  occiput.  O  puts 
firm  pressure  against  the  point  of  attack,  the  spinous  process, 
maintains  the  palm  of  his  hand  flat  to  prevent  extension  in  the 
cervical  region,  holds  the  outspread  thumb  and  finger  as  a  fulcrum 
against  which  by  raising  the  left  elbow  the  head  may  be  carried 
backward  in  extension.  The  movement  is  repeated  until  relaxa- 
tion is  secured,  when  with  a  little  additional  force  at  the  limit  of 
extension  adjustment  is  made. 

This  movement  is  corrective  for  flexion  lesions  from  the 
seventh  cervical  to  the  fourth  thoracic  usually. 

II.  SUPINE  MOVEMENT  — The  patient,  B,  's  assumed  to  be 
acutely  ill  and  suffering  from  conditions  that  are  aggravated  by  a 
flexion  lesion  of  the  fifth  thoracic.  B  lies  supine  with  his  arms 
over  his  head.  O  bends  over  him  and  places  his  hands  under  B's 
back  crossing  the  forefingers  upon  the  spinous  process  of  the  fifth 
thoracic.  B  is  asked  to  inhale  slowly  and  then  exhale  in  the 


74  OSTEOPATHIC  MECHANICS 

same  manner,  the  purpose  of  this  being  to  distract  his  attention 
and  to  secure  relaxation.  During  his  expiration  O  lifts  up  against 
the  spinous  process  of  the  vertebra  in  lesion  and  holds  the  pressure 
until  B  inhales  again.  After  several  repetitions,  at  the  conclusion 
of  expiration,  with  a  sudden  slight  increase  of  force  directed  against 
the  spinous  process  anteriorly  and  downward  towards  B's  feet, 
the  lesion  is  adjusted. 

This  movement  is  corrective  for  flexion  lesions  from  the 
second  to  seventh  dorsal  inclusive.  . 

III.  ROCKING  MOVEMENT. — B  is  assumed  to  have  a  flexion 
lesion  of  the  seventh  thoracic.     He  sits  upon  a  stool  or  the  table, 
depending  upon  the  height  of  himself  and  his  physician.     He 
clasps  his  arms  across  his  shoulders  and  leans  them  against  O's 
chest.     O  passes  his  arms  under  B's  axillae  and  around  his  back 
until  he  can  place  one  or  more  fingers  strongly  over  the  spinous 
process  of  the  vertebra  in  lesion.     O  rocks  B  forward  and  back- 
ward in  flexion  and  extension  until  relaxation  is  secured  and  then 
with  a  slight  additional  force  directed  against  the  spinous  process 
anteriorly  and  downward,  the  lesion  is  adjusted.     If  the  patient 
is  of  light  weight,  traction  may  be  very  easily  used  with  this 
movement  at  the  moment  just  before  adjustment. 

This  movement  is  effective  for  the  correction  of  lesions  from 
the  third  to  the  ninth  thoracic  inclusive  and  may  be  used  in  the 
treatment  of  patients  who  are  convalescent  after  acute  illness. 

IV.  STOOL-AND-ELBOW  MOVEMENT. — Let  B  sit  upon  a  stool 
and  clasp  his  arms  across  his  shoulders.     O  stands  to  B's  left  and 
passes  his  left  forearm  under  B's  arms  to  support  him  and  also  to 
lift  the  upper  part  of  his  body  as  a  lever.     O  places  his  right  elbow 
against  the  spinous  process  of  the  dorsal  vertebra  in  flexion  lesion, 
and  carries  his  forearm  up  against  B's  back  and  rests  the  palm  of 
the  hand  upon  his  head  to  assist  in  producing  extension  at  the 
required  time.     B  rests  much  of  his  weight  upon  O's  left  arm  and 
O  carries  B  forward  in  greater  flexion* and  then  raises  B's  arms 
and  gradually  carries  his  thoracic  area  back  in  extension  until 
the  movement  reaches  the  joint  in  lesion.     At  the  same  time  he  is 
placing  pressure  against  the  spinous  process  of  the  lesioned  verte- 
bra through  his  elbow.     The  movement  is  repeated  until  relaxa- 
tion is  complete,  and  then  with  slightly  increased  force  adjustment 
is  secured. 

This  movement  may  be  used  to  correct  flexion  lesions  from 
the  fifth  to  the  tenth  thoracic  vertebrae  inclusive.  In  place  of  the 
elbow,  pressure  may  be  made  against  the  point  of  attack  with 
the  thumb,  a  finger,  or  the  hypothenar  eminence. 


OSTEOPATHIC  MECHANICS 


75 


V.  CHEST  FORWARD  MOVEMENT.— The  patient  is  supposed 
to  have  a  flexion  lesion  of  the  eighth  thoracic.  Let  him  lie  upon 
his  face  on  the  table  and  place  his  hands,  palm  downward,  on  the 
table  beside  his  head.  He  is  asked  to  raise  his  torso  backward 
in  extension  and  then  is  directed  to  carry  the  front  of  the  thorax 
down  toward  the  surface  of  the  table  for  the  purpose  of  localizing 
the  extension.  0  may  place  his  arm  under  B's  chest  to  assist  B 


FIG.  30. — Illustrating  the  stool-and-elbow  movement. 


76  OSTEOPATHIC  MECHANICS 

in  raising  himself  from  the  table  and  to  hold  him  firmly  at  the 
moment  of  adjustment.  O  places  his  other  hand  or  thumb  against 
the  spinous  process  of  the  eighth  dorsal  and  presses  downward 
toward  B's  feet  and  anteriorly.  After  several  repetitions1  when 
relaxation  has  been  secured,  slight  additional  force  at  the  point  of 
lesion  at  the  moment  of  greatest  extension  will  adjust  the  sub- 
luxation. 

This  movement  is  corrective  for  flexion  lesions  from  the 
fifth  to  the  ninth  thoracic  inclusive. 

VI.  EXTENSION    ASSISTING    MOVEMENT. — The    patient    is 
assumed  to  have  a  flexion  lesion  of  the  third  lumbar.     He  lies 
prone  upon  the  table,  places  his  hands  as  in  the  above  movement 
and  raises  his  torso  backward  in  extension.     O  stands  beside  the 
table  and  assists  B  to  raise  his  body  by  putting  his  arm  across 
B's  chest.     O's  other  hand  is  placed  against  the  spinous  process 
of  the  third  lumbar  as  a  point  of  attack.     When  relaxation  is 
complete,  a  well  directed  increase  of  force  against  the  spinous 
process  will  adjust  the  lesion. 

This  movement  may  be  used  for  the  adjustment  of  flexion 
lesions  from  the  eighth  thoracic  to  the  fifth  lumbar  inclusive. 

VII.  ClRCUMDUCTION  EXTENSION  MOVEMENT.2 — B  sits  Upon  a 

stool  facing  O  who  stands  in  front  of  him,  encircling  him  with  his 
arms,  and  resting  his  fingers  upon  the  spinous  process  of  the 
first  lumbar  which  is  assumed  to  be  in  flexion  lesion.  B  places  his 
arms  over  O's  shoulders,  turns  his  face  to  one  side  and  rests  his 
head  against  O's  shoulder.  O  carries  B's  body  in  circumduction 
backward,  to  the  side,  forward,  to  the  other  side,  and  repeats  the 
movement.  When  he  feels  relaxation  has  been  secured,  he  stops 
the  movement  in  forward  flexion  and  quickly  carries  B  back  in 
extension  while  he  pulls  anteriorly  and  downward  upon  the  spinous 
process. 

This  movement  is  suitable  for  light-weight  patients  only  and 
may  be  best  given  with  traction  just  before  the  concluding  direc- 
tion of  force  against  the  spinous  point  of  attack. 

1.  Patients  respond  differently  to  corrective  movements.     Some  do  not 
require  a  repetition  of  any  movement.     Others  who  do  not  voluntarily  relax 
may  need  as  many  as  five  to  eight  repetitions  of  any  given  corrective  move- 
ment before  adjustment  may  be  attempted. 

2.  A  movement  that  has  been  used  t-by  many  consists  in  lifting  the  thighs 
and  pelvis  of  the  patient,  who  lies  prone  upon  the  table,  while  pressure  is 
made  properly  against  the  spinous  process  of  the  lesioned  vertebra.     The 
movement  does  not  seem  to  me  to  be  mechanically  good  for  the  reason  that 
the  superior  articular  facets  of  the  vertebra  below  must  be  forced  under  the 
inferior  facets  of  the  vertebra  above. 


OSTEOPATHIC  MECHANICS  77 

GROUP  LESIONS 

Group  lesions  may  be  corrected  just  as  individual  lesions  by 
using  less  of  final  increase  of  force  and  more  of  extension  for  the 
purpose  of  stretching  contractured  flexor  muscles.  Rest  in  the 
prone  position  for  frail  patients  is  helpful  when  the  patient's 
limbs  are  elevated  by  a  roller  of  six  inches'  diameter  placed  beneath 
the  knees  or  just  above  them.  This  brings  extension  upon  the 
lumbar  articulations  and  stretches  the  anterior  longitudinal 
ligament  and  the  discs  anteriorly. 

All  patients  should  be  advised  to  study  their  standing  posi- 
tions and  sitting  positions.  The  physician  has  not  done  his  full 
duty  to  such  a  patient  until  he  has  explained  the  equilibrium  of 
the  erect  body  and  advised  them  how  they  shall  change  faulty 
habits.  It  is  as  much  a  part  of  the  routine  examination  as  the 
finding  of  the  lesion.  Since  group  lesions  are  commonly  the 
result  of  long  continued  faulty  habit,  it  is  not  to  be  presumed 
that  recovery  may  be  made  by  the  administration  of  a  few  cor- 
rective treatments.  As  a  physician  would  give  a  sufferer  from 
chronic  nephritis  a  diet  list,  even  so  much  it  is  necessary  that  a 
physician  shall  prescribe  exercises  when  he  finds  the  occasion. 
Nor  should  the  physician  fail  to  bring  to  the  attention  of  the 
patient  the  part  of  the  cure  that  devolves  upon  himself.1  One  is 
not  justified  in  accepting  a  case  when  it  is  plain  to  be  seen  that 
the  patient  wilfully  means  not  to  concur  in  the  plan  proposed 
for  overcoming  the  condition,  which  means  that  the  cause  must 
be  removed  before  a  cure  can  be  made.2 

AFTER-TREATMENT 

Chronic  flexion  lesions  may  recur  should  the  cause  return.  It 
is  therefore  best  to  institute  a  resistance  form  of  treatment  which 


1.  It  has  been  my  custom  in  examining  patients  for  many  years,  especially 
since  I  have  been  examining  for  others  to  administer  the  treatment,  to  say  to 
the  patient  having  group  lesions:     "At  least  one-half  of  the  cure  of  your  con- 
dition depends  upon  the  faithful  performance  on  .your  part  of  the  directions 
that  shall  be  given  you  by  your  physician.     You  have  no  more  right  to  expect 
the  physician  to  cure  you  without  your  co-operation  than  the  lazy  poor  man 
has  to  expect  to  be  fed  without  toiling  for  the  means  wherewith  to  purchase 
food."     The  best  results  are  obtainable  after  such  plain  statements  as  these. 

2.  It  is  axiomatic  that  the  physician  who  inspires  confidence  in  his  patient 
is  he  who  causes  him  to  help  himself.     The  most  successful  practices  have 
been  built  by  exactly  such  observances  on  the  part  of  the  physician. 


78  OSTEOPATH ic  MECHANICS 

shall  be  directed  toward  the  strengthening  of  the  extensor  muscles 
whose  tone  has  been  lost.  The  patient  is  asked  to  lie  upon  the 
table  and  raise  his  torso  backward  in  extension  while  his  physician 
resists  with  a  moderate  degree  of  force  the  movement  by  placing 
his  hands  over  the  area  wherein  the  lesion  previously  existed. 
Secondary  extension  lesions  should  be  corrected  if  they  remain 
after  the  adjustment  of  the  primary  lesions. 

Unnecessary  flexion  movements  on  the  part  of  the  patient 
should  be  forbidden  until  the  extensor  muscles  have  gained  strength 
and  a  power  of  contractility  sufficient  to  prevent  lesion  under  the 
influence  of  ordinary  stress. 

EXTENSION    LESIONS 

An  extension  lesion  is  a  subluxation,  or  an  immobilization,  of 
a  vertebral  articulation  in  the  position  of  extension.  The  inferior 
articular  facets  of  the  vertebra  in  lesion  have  glided  downward 
upon  the  superior  articular  facets  of  the  vertebra  below  usually 
to  the  point  of  interruption  by  the  laminae  or  until  the  spinous 
processes  have  come  in  contact  and  in  this  position  immobiliza- 
tion has  resulted  from  inflammatory  changes. 

From  the  study  of  the  normal  movement  of  extension,  the 
anatomical  relations  present  in  extension  may  be  deduced : 

Spinous  process. — Approximated  to  the  one  below,  separated 
from  the  one  above. 

Body. — Slightly  posterior  at  the  anterior  inferior  margin. 

Disc. — Compressed  posteriorly  and  stretched  somewhat 
anteriorly. 

Ligaments 

I.  Stretched,  thinned,  and  atrophied 

a.  Anterior  longitudinal. 

II.  Relaxed  and  thickened,  all  posterior  ligaments. 
Intervertebral  foramina. — Narrowed  vertically  with  deposi- 
tion of  connective  tissue  lessening  their  calibre. 

Muscles. — Fasciculi  of  the  extensor  muscles  of  that  area  con- 
tractured;  corresponding  flexor  muscles  stretched  and  atrophied. 

Among  the  lumbar  vertebrae  the  one  most  commonly  in 
extension  subluxation  is  the  fifth;  among  the  dorsals,  any  one 
from  the  third  to  the  seventh.  These  lesions  occur  by  groups 
also,  the  reason  being  faulty  standing  position  due  primarily  to 


OSTEOPATHIC  MECHANICS 


79 


weakness  from  infectious  illnesses,  malnutrition,  or  hereditaiy 
tendencies;  secondarily  to  traumatism,  strain,  fibrous  ankylosis 
above  or  below;  when  extensive,  they  are  characterized  usually 
as  the  straight  spine,  and  are  caused  by  a  posterior  sacrum. 
When  present  in  the  cervical  region,  the  cause  may  be  a  bilaterally 
posterior  occiput  or  an  upper  dorsal  kyphosis. 

Extension   lesions   are   less   frequent,    when   primary,    than 
flexion  lesions,  the  reason  doubtless  being  that  they  are  less  often 

produced  by  traumatism. 
The  weight  of  the  body 
carries  the  vertebrae  into 
flexion  more  naturally 
than  into  extension,  hence 
these  lesions  would  be 
more  common.  Counter- 
balancing extension  le- 
sions are  frequent,  follow- 
ing the  occurrence  of  a 
flexion  lesion  below. 

Extension  lesions  are 
caused  by  traumatism ; 
strain,  usually  from  an 
attempt  to  regain  equili- 
brium in  falling;  concus- 
sions; infections  resulting 
in  inflammation ;  muscular 
contraction,  from  irrita- 

rvE.lWtku.^.  tion>  and  from  the  neces- 
sity of  supporting  weight 

FIG.  31. — Schematic  drawing  to  illustrate  the  ap-  ,       :„_].,     c 

proximation  of  the  spinous  process  of  the  third  thoracic     anier    )Wy,    dS 
with  the  fourth,   in  an  extension  lesion  of  the  third- 
fourth  joint.     R,  the  interspace  where  restricted  motion 
may  be  found.     The  smaller  size  of  the  circle,  indicat- 
ing the  spinous   process  of  the  third,   represents  the 


. 
lUIIlUrb. 


r»a+ior>  + 


iiijt     wuc    opiiu^urs    piuucas    ui     me     tiuiu,    icpi  cotriito     L-IIC 

flattening  seen  when  looking  at  the  line  of  spinous  unv:no.  „  harrpl  rhpst  from 
processes  in  the  back.  naVing  a  Ddrrei  Cliebl  II 

emphysema    often     may 

be  found  a  fifth  lumbar  extension  lesion.  From  the  weight  of 
the  shoulder  girdle  or  an  uncompensated  posteriorly  bilateral 
occipital  lesion  there  may  result  an  extension  lesion  of  an  upper 
dorsal  vertebra.  From  the  atroplw  of  intervertebral  discs  in  the 


80  OSTEOPATHIC  MECHANICS 

aged,  continued  contraction  of  the  lowest  fasciculi  of  the  multi- 
fidus  spinae  and  sacro-spinalis  may  result  in  an  extension  fifth 
lumbar  lesion.  High-heeled  shoes  may  also  be  cited  as  a  causal 
factor  active  in  the  same  manner. 

EXPERIMENTAL  PALPATION,  C. — Perform  again  experimental 
palpation,  A.1  If  the  fifth  thoracic  vertebra  were  immobilized 
in  extension  lesion,  there  would  be  no  separation  between  its 
spinous  process  and  that  of  the  sixth;  in  forward  flexion  and  in 
backward  extension  the  approximation  would  remain  unchanged. 
If  the  fifth  were  in  extension  lesion,  its  spine  would  be  separated 
from  the  fourth  above,  but  the  distance  between  its  spinous 
process  and  that  of  the  fourth  would  be  modified  slightly  by 
movement  because  the  fourth-fifth  articulation  is  assumed  to  be 
normal. 

The  diagnosis  of  an  extension  lesion  may  be  stated  in  these 
terms : 

THE  SPINOUS  PROCESS  OF  A  VERTEBRA  IN  EXTENSION  LESION 
IS  APPROXIMATED  TO  THE  SPINOUS  PROCESS  OF  THE  VERTEBRA 
BELOW  AND  MOVEMENT  OF  THAT  AREA  OF  THE  SPINE  DOES  NoT 
CHANGE  THE  RELATION  OF  THE  SPINOUS  PROCESSES. 

EXPERIMENTAL  PALPATION,  D. — Perform  again  experimental 
palpation,  B.2  If  the  third  lumbar  vertebra  were  immobilized  in 
extension  lesion,  there  would  be  an  approximation  between  its 
spinous  process  and  that  of  the  fourth  and  a  separation  between 
it  and  that  of  the  second.  Palpation  would  bring  out  the  fact 
that  motion  is  restricted  in  the  interspace  showing  approximation 
of  spinous  processes.  Although  separation  is  apparent  between 
the  third  and  second,  flexion  and  extension  bring  out  evidence  of 
normal  movement  in  the  articulation  of  the  second-third  lumbar 
joint. 

Differential  diagnosis  will  confirm  preliminary  diagnosis. 
An  extension  lesion  of  the  third  lumbar  may  be  differentiated  from 

1.  A  second  lumbar  flexion  lesion  by  the  separation  in  the 
latter  of  the  spinous  process  of  the  third  from  the  second  with 
restricted   movement   between   the   second   and   third   and   not 
between  the  third  and  fourth. 

2.  An  anomalous  condition  in  the  third,  a  short  spinous  pro- 
cess, by  the  presence  of  unrestricted  movement  above  and  below 
the  third  lumbar  in  the  latter  condition. 

3.  A  second  lumbar  showing  the  anomalous  condition  of  a 
long  spinous  process  by  the  detection  of  unrestricted  motion  in 


1.  See  page  67,  line  11. 

2.  See  page  69.  line  14. 


OSTEOPATHIC  MECHANICS  81 

the  second-third  lumbar  joint  and  by  the  determination  of  the 
same  amount  of  space  between  the  spinous  process  of  the  second 
and  those  of  the  third  and  first.  In  the  case  of  the  lesioned 
vertebra  there  would  be  found  restricted  motion  in  the  third- 
fourth  lumbar  joint. 

4.  An  anomalous  condition  of  the  adjacent  vertebrae,  the 
third  having  a  short  spinous  process,  the  fourth  having  a  long 
spinous  process.  Absence  of  any  restriction  of  movement  in 
either  the  second-third  or  third-fourth  spinal  joints  would  confirm 
the  diagnosis  of  irregular  spinous  processes.1 

THE  PRINCIPLE  OF  CORRECTION  FOR  EXTENSION  LESIONS  is 
FLEXION. 

GENERAL  RULES. — THE  ARTICULATING  SURFACES  MUST  RE- 
TRACE THE  PATH  THEY  TOOK  IN  THEIR  DISPLACEMENT.  The  best 

leverage  is  obtained  by  means  of  pressure  directed  downward 
through  the  bodies  of  the  vertebrae  as  low,  perhaps,  as  the  eighth 
thoracic  or  from  below  by  flexion  of  the  knees  against  the  abdomen 
localizing  as  much  as  possible  the  force  at  the  point  of  lesion  by 
making  the  spinous  process  the  fulcrum  between  the  power  arm 
and  the  weight  arm.  This  method  of  correction  is  available  in 
some  patients  as  high  as  the  tenth  dorsal. 

Correction  of  middorsal  extension  lesions  or  in  fact  of  any 
of  the  dorsal  extension  lesions,  is  not  without  its  difficulties,  for 
these  lesions  afford  less  opportunity  for  direct  leverage,  and  due 
to  the  thickening  of  relaxed  ligaments  and  proliferation  about  the 
lesioned  joint,  the  adjustment  is  of  ten  a  problem  deserving  serious 
consideration.  Preparatory  treatment  is  usually  required.  It 
should  be  of  such  a  nature  that  all  ligaments  shall  receive  physio- 
logical stimulation,  by  putting  the  joint  through  every  possible 
movement,  in  particular  the  movements  of  rotation-sidebending 
and  sidebending-rotation.  For  the  upper  five  or  six  thoracics  this 
is  often  best  accomplished  with  the  patient  lying  upon  the  side 
facing  the  physician,  who  carries  the  patient's  head  upon  his 
forearm  while  his  hand  protects  the  neck  and  prevents  a  waste  of 
force  in  rotation  and  sidebending  in  the  cervical  area;  the  thumb 
of  the  other  hand  is  placed  above  each  upper  thoracic  spinous 


1.  Extension  lesions  have  been  spoken  of  in  the  earlier  literature  of 
osteopathy  as  anterior  spinal  lesions  for  the  reason  that  the  spinous  process  by 
its  approximation  to  the  one  below  has  appeared  to  be  anterior  in  the  line  of 
spinous  processes. 


82  OSTEOPATHIC  MECHANICS 

process  in  turn  while  the  head  is  turned  toward  the  upper  shoulder 
preceded  by  a  slight  amount  of  face-turning.  The  thumb  is  then 
placed  beneath  the  spinous  process  to  pull  it  upward  while  the 
head  is,  after  slight  flexion,  sidebent  to  the  upper  shoulder,  face- 
turning  to  the  table  preceding  the  sidebending.  After  these  two 
movements,  attempted  flexion  and  extension  of  the  articulation 
should  be  made  before  an  exact  corrective  movement  is  given. 

CORRECTIVE  MOVEMENTS 

VIII.  BEDSIDE   MOVEMENT. — Let   us   assume   an  extension 
lesion  of  the  second  thoracic.     B  lies  supine  upon  the  table.     () 
places  one  hand  upon  B's  second  ribs  anteriorly,  while  the  first 
finger  of  the  other  hand  reaches  underneath  B's  neck  to  exert  a 
prying  force  upward  on  the  spinous  process  of  the  second  dorsal 
toward  the  head  which  rests  upon  O's  forearm.     The  two  hands 
work  simultaneously. 

This  may  be  used  with  advantage  in  bedside  treatment  for 
any  one  of  the  four  upper  dorsals.  It  depends  somewhat  upon 
the  tension  that  exists  at  the  joint,  whether  a  decided  increase  of 
force  is  required  at  the  conclusion  for  adjustment. 

IX.  VERTEX  PRESSURE  MOVEMENT. — It  is  assumed  that  B 
has  an  extension  lesion  of  the  fifth  dorsal.     B  sits  upon  the  table, 
O  standing  behind  him.     B  is  directed  to  clasp  his  hands  and  place 
them  upon  the  top  of  his  head.     O  carries  his  arms  under  B's 
axillae  and  reaching  up  grasps  his  wrists.     He  pulls  straight  down- 
ward to  direct  the  line  of  force  through  the  vertebral  bodies  and 
intervertebral  discs.     B  is  then  carried  forward  and  backward 
until  by  his  muscle  sense  O  ascertains  at  what  angle  he  may  best 
compress  the  fifth-sixth  disc.*     O  may  make  posterior  pressure 
against  the  angles  of  the  ribs,  as  high  as  the  fifth  for  the  purpose 
of  assisting  to  force  the  vertebra  into  flexion  by  the  pull  upon  the 
transverse  processes.2     The  pull  downward  upon  the  top  of  the 
head  exerts  a  tremendous  force  and  should  be  carefully  used. 

This  corrective  movement  will  adjust  any  midthoracic 
extension  lesion. 


1.  One  should  always  attempt  to  localize  sharply  any  corrective  move- 
ment. 

2.  The  danger  sometimes  met  with  in  a  careless  performance  of  this  move- 
ment is  that  the  osteopath  may  forget  that  flexion  is  the  corrective  principle 
and  by  carelessly  swinging  the  patient  backward,  may  cause  a  secondary 
extension  lesion  below  or  above. 


OSTEOPATHIC  MECHANICS 


83 


FIG.  32. — Illustrating  the  vertex  pressure  movement. 


X.  SPINOUS  FIXED  POINT  MOVEMENT. — It  may  be  assumed 
that  B  has  an  extension  lesion  of  the  seventh  thoracic.  B  sits 
upon  a  stool  while  O  stands  at  his  side.  O  places  his  thumb 
upon  the  spinous  process  of  the  eighth  thoracic  as  a  fixed  point 
and  maintains  a  firm  pressure  thereon.  (This  movement  is  illus- 
trated by  figure  26,  page  68.)  O  places  his  other  hand  upon  B's 
head  to  produce  flexion  of  the  upper  thoracic  area.  He  moves 
B's  head  forward  in  flexion  until  he  finds  the  angle  at  which 
increased  force  may  adjust  the  lesion.  He  then  brings  a  force 
downward  upon  the  top  of  B's  head  and  through  the  vertebral 
bodies  and  discs  until,  by  the  opposition  of  the  force  directed  against 
the  fixed  point,  the  two  forces  meet  and  the  seventh-eighth  arti- 
culation is  adjusted.  O  may  place  his  knee  in  the  lumbar  area  of 
B's  spine  to  hold  that  area  in  extension. 

This  movement  may  be  used  to  adjust  extension  lesions  of 
any  of  the  thoracic  vertebrae  from  the  second  to  the  ninth,  inclusive. 


84 


OSTEOPATHIC    MECHANICS 


FIG.  33. — Illustrating  the  knee  leverage  movement. 

XL  LONG  LEVER  MOVEMENT. — B  is  assumed  to  have  an 
extension  lesion  of  the  eleventh  thoracic.  B  sits  upon  the  side 
of  the  table.  O  sits  upon  a  high  stool  close  to  the  table  with  his 
knees  under  the  edge  of  the  table  by  means  of  which  he  may  brace 
himself  in  order  to  exert  a  strong  pull  downward.  B  clasps  his 
hands  easily  upon  the  top  or  the  back  of  his  head.  O  passes  his 
hands  under  B's  axillae  and  up  over  his  chest  grasping  B's  shoulders 
as  near  to  the  nape  of  his  neck  as  possible.1  B  is  then  asked  to 
flex  his  body  forward  while  O  tests  the  angle  of  forward  flexion 
required  to  bring  the  force  most  directly  downward  through  the 
vertebral  bodies  and  the  discs  against  the  eleventh-twelfth  disc 
which  is  stretched  anteriorly.  The  adjustment  is  made  by  a 
strong  pull  downward. 

XII.  KNEE  LEVERAGE  MOVEMENT.— B  is  assumed  to  have 
an  extension  lesion  of  the  fifth  lumbar.  He  lies  upon  his  back  on 
a  low  table  with  his  knees  flexed  against  his  abdomen.  O  places 
his  chest  against  B's  knees,  his  hands  under  B's  spine  to  assist  in 
guiding  the  direction  of  force.  Sufficient  pressure  is  brought 

1.  O's  hands  should  be  applied  to  the  nape  of  B's  neck  rather  than  to  the 
top  of  his  head  or  to  his  neck,  for  the  fault  of  the  lever  is  its  length,  which  for 
mechanical  advantage  should  be  shortened  as  much  as  possible. 


OSTEOPATHIC  MECHANICS  85 

against  B's  knees  and  through  them  transmitted  to  the  contracted 
and  shortened  muscles  and  ligaments  of  the  articulation  in  lesion, 
to  effect  a  separation  and  adjust  the  lesion.  B  should  then  be 
turned  upon  his  side  with  a  firm  hold  upon  the  spinous  process  of 
the  vertebra  recently  in  subluxation,  while  extension  is  made  of 
the  joint  above.  The  joint  should  then  be  put  through  sidebend- 
ing-rotation,  and  the  patient  directed  to  practice  flexion  exercises 
for  a  few  days,  such  as  bending  to  touch  the  hands  to  the  floor 
from  the  erect  position,  taking  care  not  to  pass  the  normal  erect 
posture  upon  the  return  movement,  nor  to  use  the  lower  fasciculi 
of  the  sacro-spinalis  and  multifidus  spinse  to  pull  himself  up.  A 
chair  may  be  placed  beside  him  which  he  may  use  to  help  regain 
the  erect  position. 

XIII.  FLOOR  MOVEMENT. — The  patient  presents  an  extension 
lesion  of  the  third  lumbar.  By  reason  of  an  ankylosed  knee  and 
corpulence,  B  cannot  be  treated  by  movement  XII.  B  is  asked  to 
lie  comfortably  upon  the  floor.  O  grasps  B's  feet  and  carries 


IMG.  34. — Illustrating  the  floor  movement  for  an  extension  lesion  of  a  lumbar  vertebra. 


86  OSTEOPATHIC  MECHANICS 

them  over  his  shoulder.  He  then  steps  between  B's  legs  and  bends 
forward  taking  hold  of  his  thighs  just  above  the  knees.  He 
raises  B's  hips  and  carries  them  back  toward  the  floor  a  few  times. 
until  he  has  acquired  a  knowledge  of  the  exact  angle  at  which 
adjustment  may  be  obtained.  Pushing  forward  with  the  shoulders 
against  B's  heels,  and  pulling  backward  and  thrusting  downward 
upon  B's  thighs,  a  sudden  increase  of  force  is  applied  and  the 
adjustment  made. 

Group  lesions  may  be  overcome  by  any  method  which  has 
for  its  purpose  the  development  of  tone  in  stretched  muscles,  a 
stretching  of  contractured  muscles,  and  the  return  to  the  normal 
of  atonic  ligaments.  Flexion  and  extension  with  the  patient  lying 
upon  the  side  is  suggested  for  such  patients.  Forcible  flexion  of 
each  joint  in  turn  with  the  patient  supine  at  the  end  of  the  table, 
knees  flexed  against  the  abdomen,  and  legs  against  the  thighs  is 
recommended.  This  last  movement  is  the  one  which  most  quickly 
relieves  the  sacral  pain,  which  is  the  common  accompaniment  of 
extension  lesions  of  the  lower  lumbars,  in  fact  it  is  palliative  in 
cases  of  lumbago  from  unconnected  sidebending-rotation  lesion 
of  any  lumbar  vertebra. 


OSTEOPATHIC  MECHANICS 


87 


CHAPTER  V. 
ROTATION  AND  SIDEBENDING  LESIONS 

ROTATION    LESIONS 

A  rotation1  lesion  is  a  subluxation,  or  an  immobilization,  of  a 
thoracic  or  cervical  vertebral  articulation  in  the  position  of  rota- 
tion. In  application  of  the  above  definition  a  third  thoracic 
rotation  lesion  to  the  right  may  be  defined  as  a  lesion  in  which  the 
third-fourth  thoracic  joint  is  immobilized  in  the  position  of  rota- 
tion to  the  left. 

In  the  normal  movement  of  spinal  rotation,  it  has  been 
observed  that  the  body  of  the  vertebra  rotates  toward  the  side 
toward  which  torso  rotation  takes  place;  that,  by  the  rotation  of 


FIG.  35. — Schematic  drawing  to  illustrate  the  rotation  of  the  third  thoracic  vertebra  in  a 
left  rotation  lesion  of  the  third-fourth  thoracic  joint.  The  arrows  represent  the  direction 
toward  which  the  spinous  processes  point.  The  circles,  the  bodies  of  the  vertebrae.  The 
horizontal  lines,  the  transverse  processes.  The  heavy  line,  the  right  transverse  process  approx- 
imated to  that  of  the  fourth  and  posterior.  The  light  line,  the  left,  separated  from  the  fourth 
and  anterior.  The  dotted  lines,  the  concavity  and  convexity  in  the  general  movement  of 
rotation  to  the  right. 

1.  The  whole  term  for  the  lesion  should  be  rotation-sidebending,  but 
for  the  purpose  of  simplifying  the  terminology,  the  second  word  has  been 
discarded. 


88  OSTEOPATHIC  MECHANICS 

the  whole  vertebra,  the  spinous  process  turns  to  the  opposite  side: 
that  each  vertebra  has  tilted  as  a  whole  toward  the  side  toward 
which  it  has  rotated,  and  that  the  transverse  process  upon  that 
side  has  moved  backward  and  is  also  inclined  sidewise  because 
rotation  in  the  spinal  column  is  never  a  simple  movement.1 

If  by  reason  of  strain  or  any  of  the  causes  which  are  opera- 
tive in  the  production  of  lesion,  a  thoracic  vertebra  should  be 
immobilized  in  the  position  of  rotation,  the  relation  of  the  anatom- 
ical structures  would  be  as  follows,  assuming  that  the  third  thoracic 
has  been  the  one  immobilized  in  rotation  to  the  left : 

1.  Spinous  process  to  the  right. 

2.  Left  transverse  process  posterior  in  relation  to  the  second 
and  fourth,  approximated  to  the  fourth,  separated  from  the  second. 

3.  Right  transverse  process  slightly  anterior  in  relation  to 
adjacent  transverse  processes,  separated  from  the  fourth,  approxi- 
mated to  the  second. 

4.  Vertebral  body  rotated  toward  the  left. 

5.  Intervertebral  disc  compressed  upon  the  left  and  spread 
upon  the  right. 

6.  Perpendicular  line   projected   upward   from   the   superior 
surface  of  the  vertebral  body  inclined  to  the  left. 

7.  Intervertebral  foramen  on  the  left  narrowed  vertically,  on 
the  right  widened  vertically. 

8.  The  third  left  rib  slightly  posterior  to  the  adjacent  ribs. 
approximated  to  the  fourth,  separated  from  the  second. 

9.  The  third  right  rib  slightly  anterior  to  adjacent  ribs,  separat- 
ed from  the  fourth  rib  and  approximated  to  the  second  rib. 

10.  Ligamentous  changes. — On  the  left  the  anterior    longi- 
tudinal, lateral  spinal,  capsular,  and  flava  ligaments,  in  particular, 
are  shortened  and  thickened;   on  the  right  the  same  ligaments  are 
stretched,  thinned,  and  atrophied. 

1 1 .  Muscles. — Fasciculi  of  the  multifidus,  semispinalis,  and  the 
rotatores  are  contractured  on  the  right,  stretched  and  atrophied 
on  the  left. 

EXPERIMENTAL  PALPATION,  E. — Ask  the  patient,  B,  who  is 
assumed  to  have  a  rotation  lesion  of  the  third  thoracic  to  the  right,2 
to  sit  upon  a  stool  in  front  of  O,  who  inspects  the  upper  part  of 

1.  See  page  22. 

2.  Rotation  lesions  are  named  according  to  the  direction  toward  which 
the  spinous  process  turns;  thus,  a  rotation  lesion  of  the  third  thoracic  means 
that  the  spinous  process  is  turned  toward  the  right;  the  body  of  the  vertebra, 
which  of  course  may  not  be  seen  in  inspection  of  the  back,  is  turned  to  the 
left.     The  osteopathist  has  named  the  lesion  from  what  he  has  seen. 


OSTEOPATHIC  MECHANICS  89 

his  back.  If  B  is  not  too  well  covered  with  adipose  tissue,  the 
spinous  process  of  the  third  thoracic  will  be  seen  to  be  out  of  aline- 
ment  with  those  above  and  below,  being  slightly  to  the  right.  It 
may  be  necessary  to  have  B  flex  his  head  slightly  and  cross  his 
arms  easily  in  his  lap  to  bring  into  view  the  deviation  of  the  spinous 
process  of  the  third.  A  deviation  of  the  spinous  process  above,  or 
of  the  one  below,  may  be  noted  at  the  same  time.  B  should  be 
asked  to  turn  his  head  to  the  right  and  then  to  the  left.  It  will  be 
noted  that  rotation  to  the  left  is  much  more  easily  accomplished. 

0  should  place  his  finger-tips  between  the  spinous  processes  of 
the  third  and  fourth  and  of  the  second  and  third  thoracic  vertebrae. 
With  his  hand  upon  the  top  of  B's  head,  O  should  produce  the 
normal  movements  in  B's  spine,  noting  whether  or  not  there  are 
changes  in  the  distance  between  the  spinous  processes.  If  there  is 
restricted  or  lost  motion  in  the  third-fourth  thoracic  joint,  there  will 
be  no  change  in  the  relation  of  the  vertebrae  upon  movement.  In 
the  presence  of  lesion  of  the  third  only,  movement  should  be  present 
in  the  second-third  joint. 

For  the  palpation  of  the  thoracic  joints  in  normal  rotation,  the 
fingers  should  be  placed  along  the  lateral  margins  of  the  spinous 
processes  for  the  purpose  of  comparing  the  movement  of  the  spinous 
processes  as  the  vertebrae  rotate  normally.  When  the  head  is 
turned  to  the  left,  it  may  be  noted  that  the  first  thoracic  spinous 
process  turns  to  the  right  slightly  beyond  the  second,  the  second 
beyond  the  third,  and  so  on  down  the  spinal  column  as  far  as  rota- 
tion is  the  normal  function  of  the  spinal  joints. 

When  a  rotation  lesion  of  the  third  thoracic  is  present,  turning 
the  head  to  the  right  or  left  does  not  cause  the  spinous  process  of 
the  third  to  move  laterally. 

0  should  then  palpate  the  in  tertrans verse  spaces  to  note 
whether  or  not  the  left  third-fourth  interspace  is  wider  than  the 
right;  he  should  also  palpate  the  left  transverse  process  and  the 
left  third  rib,  both  of  which  should  be  prominent  posteriorly. 

Counterbalancing  lesions  are  usually  present  and  they  are  of 
the  same  type  as  the  primary  lesion,  that  is,  a  rotation  lesion  to 
the  right  will  induce  a  rotation  lesion  to  the  left  in  a  vertebra 
above  or  below,  most  commonly  in  the  vertebra  immediately 
above.  The  induced  or  secondary  lesion  has  for  its  purpose 
restoration  of  normal  balance  and  therefore  lacks  many  of  the 
characteristics  of  the  primary  lesion.  Its  relations  to  the  vertebra 
below  are  the  same  as  regards  osseous  processes,  but  the  soft 
tissues  show  no  pathological  effects.  Contractions  of  muscles 
may  be  found  but  no  contractures.  If  foramina  are  narrowed,  the 


90  OSTEOPATHIC  MECHANICS 

effects  are  minimum.  Correction  of  the  primary  lesion  is  sufficient 
in  ordinary  cases  for  as  soon  as  equilibrium  is  restored,  secondary 
effects  have  no  further  reason  to  exist.  A  small  amount  of  direct 
work  will  overcome  them  should  they  remain. 

The  diagnosis  of  the  secondary  lesion  depends  upon  two  things, 
the  appearance  when  at  rest  of  a  lesion  to  the  opposite  side  and 
the  presence  of  unrestricted  motion  in  the  joint  when  subjected 
to  experimental  palpation. 

Differential  diagnosis  is  determined  by  the  functional  test  of 
motion.  A  right  rotation  lesion  of  the  third  thoracic  is  to  be 
differentiated  from  a  deflected  spinous  process  of  the  same  vertebra 
by  the  presence  of  normal  movement  in  the  joint  and  by  the 
absence  of  a  counterbalancing  lesion.  Differentiation  from  a 
sidebending  lesion  will  be  considered  later.1 

Rotation  subluxations  occur  as  low  as  the  tenth  thoracic; 
below  the  tenth  they  are  traumatic  in  character  and  the  patho- 
logical changes  in  the  articulation  are  greater,  the  symptoms  more 
severe,  and  correction  less  easily  accomplished.  The  causes 
operating  to  produce  rotation  lesions  are  those  mentioned  before.2 

CORRECTIVE  MOVEMENTS 

THE  PRINCIPLE  OF  CORRECTION  FOR  ROTATION  LESIONS  IS 
ROTATION  TO  THE  OPPOSITE  SIDE. 

GENERAL  RULES. — SINCE  ROTATION  is  ALWAYS  ACCOM- 
PANIED BY  SIDEBENDING  A  ROTATION  LESION  MAY  BE  CORRECTED 
BY  PLACING  THE  PATIENT  IN  THE  POSITION  OF  ROTATION  AND  USING 
THE  MOVEMENT  OF  SIDEBENDING  FOR  ADJUSTMENT. 

Replacement  of  rotation  lesions  of  the  upper  thoracic  area 
should  be  made  with  the  patient  in  the  erect  or  moderately  flexed 
position  for  the  reason  that  rotation  is  normal  to  this  area  in  either 
of  these  positions. 

Rotation  lesions  of  the  eighth,  ninth,  and  tenth  thoracic 
vertebrae  should  be  corrected  with  the  patient  erect. 

Rotation  lesions  at  the  dorsolumbar  junction,  when  not  trau- 

1.  See  page  105,  the  last  line. 

2.  See  page  10,  paragraph  2.     That  which  has  been  said  concerning  the 
gradual  production  of  flexion  lesions  (page  71,  line  20)  might  be  applied  to  the 
production  of  other  lesions. 


OSTEOPATHIC  MECHANICS 


91 


inatic  lesions,  are  produced  by  strain  with  the  patient  in  a  position 
of  hyperextension,  therefore,  hyperextension  is  the  regular  posi- 
tion for  indicated  corrective  purposes. 

Traumatic  lesions1  of  the  lumbar  area  may  be  corrected  with 
the  patient  in  the  position  of  hyperextension;  they  are  better 
adjusted  by  using  the  normal  movement  of  that  area,  sidebending; 
they  are  most  successfully  overcome  by  the  traction  method2  of 
correction. 

I.  HEAD-LEVERAGE  MOVEMENT. — A  patient,  B,  is  assumed  to 
have  a  right  rotation  lesion  of  the  third  thoracic  vertebra.  Ask 
B  to  lie  upon  his  left  side  on  the  table.  O  stands  beside  the  table 
facing  him.  O  lifts  B's  head  and  rests  it  upon  his  right  forearm, 
his  hand  encircling  B's  neck  for  the  purpose  of  protecting  the 


FIG.  36. — Illustrating  the  head-leverage  movement" for  a  left  rotation  lesion  of  the  third 
thoracic  vertebra. 


1.  See  page  11,  paragraph  5. 

2.  See  page  72,  paragraph  2. 


92  OSTEOPATHIC  MECHANICS 

cervical  area  against  possible  strain.  O  places  the  thumb  of  his 
left  hand  against  the  upper  or  right  side  of  the  spinous  process  of 
the  vertebra  in  lesion. 

O  turns  B's  face  toward  the  right  in  an  arc  of  about  thirty 
degress  and  then  sidebends  B's  head  to  the  right  until  the  tension 
of  the  protective  musculature  is  overcome.  In  securing  this  relaxa- 
tion it  may  be  necessary  to  make  a  few  movements  of  flexion  and 
extension  among  the  movements  aimed  at  correction.  When 
relaxation  is  complete,  O  simultaneously  exerts  an  additional  amount 
of  pressure  against  the  spinous  process  and  carries  the  head  to  the 
fullest  extent  of  sidebending.  It  is  common  for  the  last  movement 
to  be  finished  with  a  slight  popping  sound,  but  it  must  not  be 
supposed  that  this  sound  reports  the  adjustment  of  the  lesion.  It 
is  probably  the  sound  occasioned  by  the  separation  of  articular 
facets.  The  adjustive  movement  must  be  continued  beyond  the 
moment  of  the  popping  noise. 

Some  assistance  in  localizing  the  movement  to  the  upper 
thoracic  area  may  be  had  by  O's  resting  his  chest  against  B's  right 
shoulder  and  the  lateral  wall  of  his  thorax,  the  pressure  against  his 
ribs  holding  the  vertebrae  below  the  one  in  lesion  immobile. 

II.  SHOULDER-LIMITING  MOVEMENT. — Let  B  sit  upon  the  end 
of  the  table.     O  should  stand  to  his  left  and  slightly  behind  him. 
O  places  his  left  axilla  over  B's  left  shoulder,  his  forearm  against 
the  side  of  B's  head,  his  hand  on  the  top  of  B's  head.     O  places 
his  right  thumb  against  the  right  side  of  the  third  thoracic  spinous 
process  and  exerts  pressure  in  an  effort  to  move  it  to  the  left  and 
turn  the  body  of  the  vertebra  from  the  left  toward  the  right.     At 
the  same  time  O  turns  B's  head  toward  the  right  slightly  and  then 
sidebends  the  head  to  the  same  side,  performing  a  series  of  side- 
bending  movements    to  secure  relaxation.     O  maintains  a  firm 
pressure  downward  upon  B's  shoulder  to  limit  the  area  of  side- 
bending  to  that  controlled  by  the  leverage  of  head  and  neck.     When 
relaxation  is  complete,  a  slight  increase  of  pressure  against  the 
point  of  attack,  the  spinous  process,  and  an  added  impetus  to  side- 
bending  will  adjust  the  lesion.     If  the  popping  sound  should  be 
heaid,  sidebending  must  be  carried  a  degree  further. 

The  movements  above  wilf  adjust  any  rotation  lesion  of  the 
upper  four  thoracic  vertebrae. 

III.  RIB-LEVERAGE  MOVEMENT. — Let  B  sit  upon  a  stool.    O 
stands  to  the  right  and  in  front  of  B.     He  places  his  right  arm  under 
B's  left  axilla  and  rests  his  middle  finger  upon  B's  left  third  rib,  the 
one  which  is  prominent  posteriorly  in  a  right  rotation  lesion  of  the 
third  thoracic  vertebra.     O's  left  thumb  should  be  placed  against 
the  right  side  of  the  spinous  process  of  the  third  in  the  effort  to 


OSTEOPATHIC  MECHANICS  93 

turn  it  toward  the  left.  By  pulling  with  his  right  arm  or  by  press- 
ing against  B's  right  shoulder  with  his  shoulder,  O  turns  B  toward 
the  right  in  simple  rotation.  When  relaxation  has  been  secured, 
adjustment  is  made  by  a  slight  increase  in  rotation  and  an  additional 
amount  of  pressure  against  the  angle  of  the  third  rib.  B  may  rest 
his  head  against  O's  chest  in  ease,  turning  his  face  to  the  right  when 
the  lesion  is  a  right  rotation  lesion. 

The  minutise  of  the  above  movement  may  be  changed  to  suit 
the  case.  In  large  patients,  O's  left  hand  may  be  placed  against 
B's  right  shoulder  to  make  the  rotation  more  forceful.  B  should 
be  turned  as  far  to  the  right  as  possible  and  at  the  moment  of  adjust- 
ment turned  still  farther.1  O  may  place  the  forefinger  of  his  left 
hand  against  the  left  side  of  the  spinous  process  of  B's  fourth  thoracic 
vertebra,  to  make  a  fixed  point  against  which  to  rotate  the  area 
above. 

This  movement  may  be  used  to  adjust  rotation  lesions  of  the 
thoracic  vertebrae  from  the  third  to  the  eighth  inclusive. 

IV.  FORWARD-BENDING  MOVEMENT. — B  is  assumed  to  have  a 
right  rotation  lesion  of  the  eighth  thoracic  vertebra.  Let  B  sit 
upon  a  stool,  while  0  stands  to  his  right  and  bends  forward  until 
his  back  is  level  with  B's  right  axilla.  B  is  asked  to  turn  very 
slightly  and  place  both  arms  across  O's  back.  0  places  his  right 
arm  across  B's  chest,  under  his  left  axilla,  his  hand  over  B's  left 
ribs  from  the  sixth  to  the  ninth.  O's  left  thumb  pushes  against 
the  spinous  process  of  the  eighth  thoracic  for  the  purpose  of  turning 
the  vertebra  from  the  left  toward  the  right.  Simultaneously  O 
rotates  B's  body  to  the  right  by  pulling  with  his  right  hand  and 
swinging  his  own  bdy  forward. 

Several  movements  are  made,  aimed  at  correction.  When 
relaxation  has  been  obtained,  rotation  is  carried  as  far  as  possible 
and  completed  with  an  extra  forcible  movement,  which  should 
adjust  the  lesion  if  both  hands  work  in  unison  and  the  action  is 
rightly  timed. 

The  movement  may  be  varied  by  having  0  put  the  corrective 
pressure  against  the  prominent  eighth  left  rib,  while  with  his  left 
hand  he  grasps  B's  right  wrist  and  by  swinging  his  weight  forward 
rotates  B's  body  farther  to  the  right  and  then  finishes  the  movement 

1.  There  is  a  certain  knack  in  knowing  when  the  tension  of  muscles  has 
been  released  sufficiently  to  warrant  an  attempt  at    adjustment     This  is 
acquired  after  many  months  of  practice  and  it  is  the  result  of  the  cultivation 
of  the  sensations  coming  from  muscles,  tendons,  and  joints. 

2.  It  is  held  by  many  osteopathists  that  adjustment  is  made  of  the  whole 
area  above,  including  the  vertebra  in  lesion,  to  the  vertebra  below.     In  the 
case  cited,  the  spine  from  the  third  dorsal  up  would  be  considered  adjusted 
to  the  fourth  dorsal  when  the  third-fourth  joint  became  normalized. 


94 


OSTEOPATHK;  MECHANICS 


FIG.  37. — Illustrating  the  pressure  of  the  thumb  against  the  spinqus  process  in  the  cor- 
rection of  a  rotation  lesion  of  the  tenth  dorsal  to  the  left.  The  arrow  points  to  the  side  toward 
which  the  rotation  of  the  body  for  correction  should  be  made. 

with  secondary  sidebending  which  adds  compression  on  the  right 
to  the  intervertebral  disc  between  the  eighth  and  ninth  thoracic 
vertebrae,  gaps  the  articulation  on  the  left  and  causes  the  left  side 
of  the  disc  to  rebound. 

This  movement  will  adjust  rotation  lesions  from  the  sixth  to 
tenth  thoracic  inclusive. 

V.  HALF-LEANING  MOVEMENT. — B  is  assumed  to  have  a  right 
rotation  lesion  of  the  fifth  thoracic  vertebra.  Let  B  sit  well  back 
upon  a  stool,  behind  which  O  sits  on  a  table.  O  leans  slightly 
forward  and  B  rests  comfortably  backward  against  O's  right 
shoulder.  O  places  the  thumb  of  his  left  hand  against  the  angle 
of  the  fifth  left  rib  or  against  the  left  transverse  process  of  the  fifth 
thoracic  vertebra.  O  places  his  right  arm  around  B,  under  his 
right  axilla  and  forward  until  he  lays  his  hand  over  the  anterior 
extremity  of  the  left  fifth  rib.  O  rotates  B's  torso  slightly,  lifting 
a  little  on  the  fifth  rib  from  both  extremities.  When  relaxation 


OSTEOPATHIC  MECHANICS  95 

is  felt  to  be  complete,  a  sudden  increase  of  rotation  and  of  pressure 
against  the  posterior  extremity  of  the  fifth  rib  will  adjust  the  lesion. 

This  corrective  movement  is  suitable  for  the  adjustment  of 
rotation  lesions  of  the  fifth  to  ninth  thoracic  vertebrae  inclusive. 

VI.  TRACTION  SIDEBENDING  MOVEMENT. — B  is  assumed  to 
have  a  right  rotation  lesion  of  the  tenth  thoracic.     B  sits  upon  a 
low  stool.     0  stands  in  front  of  B  and  to  the  left.     He  places  his 
left  knee  inside  of  B's  knees  to  assist  in  making  immobile  B's  pelvis. 
O  reaches  around  B  with  both  arms,  under  B's  axillae,  and,  if  B  is 
not  too  large,  he  grasps  the  spinous  process  of  the  eleventh  thoracic 
vertebra  from  the  left  side  to  make  of  it  a  fixed  point.     With  his 
right  hand  he  takes  a  firm  hold  upon  the  upper  part  of  B's  spine  or 
under  his  left  scapula,  or  he  may  grasp  the  spinous  process  of  the 
vertebra  in  lesion  to  pull  it  toward  the  left.     0  then  swings  B  in 
gentle  rotation  to  the  right,  lifts  B  with  slight  traction,  and  as  soon 
as  he  feels  resistance  is  overcome,  he  sidebends  B  to  the  right. 
The  secondary  sidebending  with  the  holding  of  the  vertebra  below 
immovable  should  not  fail  to  adjust  any  rotation  lesion  of  a  lower 
thoracic  vertebra.     If  the  rotation  lesion  is  of  the  last  two  thoracics 
or  upper  two  lumbars,  B  may  be  carried  back  in  some  hyper- 
extension  before  the  rotation  is  begun  and  the  hyperextension  must 
be  maintained  through  the  movement. 

VII.  HOOP-ROLLING  MOVEMENT. — B  is  assumed  to  have  the 
same  lesion  as  in  the  last  instance.     He  lies  upon  his  left  side  upon 
the  table.     O  stands  in  front  of  him,  and  places  his  right  hand 
against  B's  right  shoulder  or  in  his  right  axilla.     O'  directs  B  to 
place  his  left  leg  behind  the  right  on  the  able  and  bend  the  right 
leg  at  the  knee.     O  puts  his  left  forearm  on  B's  right  hip,  a  finger 
against  the  left  side  of  the  eleventh  thoracic  spinous  process  to 
make  of  it  a  fixed  point.     O  rotates  B's  torso  to  the  right  by  push- 
ing his  right  shoulder  backward.     He  may  need  to  repeat  the  opera- 
tion several  times  until  resistance  has  been  overcome,  when  by  a 
sudden  increase  of  rotation  the  tenth  thoracic  returns  to  normal 
alinement  with  the  eleventh. 

AFTER-TREATMENT 

Rotation  lesions  that  may  be  said  to  be  in  the  chronic  stage, 
are  often  exceedingly  difficult  to  adjust;  they  require  time  and 
patience  on  the  part  both  of  physician  and  patient,  skill  to  accom- 
plish the  correction,  and  care  to  avoid  a  recurrence  of  the  devia- 
tion from  the  normal  alinement.  Atrophic  muscles  must  be 
stimulated  to  recovery;  to  that  end  patients  must  be  advised  to 


96  OSTEOPATHIC  MECHANICS 

take  exercises  which  will  bring  tone  to  these  muscles,  the  best  of 
which  would  be -strong  rotation  to  the  side  of  the  spinous  procrs>. 
Since  the  patient  knows  practically  nothing  of  the  condition  of 
his  or  her  spine,  he  or  she  must  be  told  to  which  side  to  turn  the 
head  and  body.  If  the  lesion  is  the  common  rotation  lesion  of 
the  second  thoracic,  an  excellent  exercise  which  localizes  the  action 
almost  directly  at  the  joint  in  lesion  is  first,  extreme  flexion  of 
the  head  and  upper  part  of  the  body,  then  turning  the  head  as 
far  as  possible  to  the  side  of  the  spinous  process.  It  has  been 
pointed  out  that  in  extreme  flexion  rotation  is  limited  to  the  last 
two  cervical  and  upper  two  thoracic  vertebrae.1 

Muscles  that  were  contractured  must  be  given  no  opportunity 
to  contract  strongly;  for  that  reason  it  is  often  required  of  the 
physician  to  enumerate  the  actions  that  tend  to  reproduce  the 
lesion,  as,  upward  reaching  with  the  arms,  often  followed  by  a 
lowering  of  heavy  objects  which  necessitates  a  turning  of  the  head 
to  get  it  out  of  the  waj',  or  unusually  strong  action  of  one  arm : 
the  habit  of  turning  the  head  toward  objects  which  have  been  put 
in  a  certain  place  that  for  the  individual  is  harmful,  as,  a  clock,  an 
outside  window,  a  chart,  a  mirror,  a  book  of  reference;  the  knee- 
chest  position  with  the  head  not  turned  to  the  side  of  the  spinous 
process;  sleeping  on  the  chest  with  the  face  turned  to  the  side: 
sleeping  on  the  side  with  a  pillow  that  is  too  high  so  that  the  head 
is  sidebent  in  the  position  of  rest;  napping  in  a  chair  with  the 
head  dropping  over  the  shoulder.  In  the  case  of  lower  dorsal 
lesions,  heavy  lifting  with  one  arm  is  the  most  frequent  cause  of 
the  recurrence  of  the  lesion.  Students  having  rotation  lesions 
should  be  especially  careful  about  their  sitting  positions  in  study- 
ing and  writing. 

LATERAL  LUMBAR  LESIONS 

When  the  spinous  process  of  a  lumbar  vertebra  is  out  of  aline- 
ment  with  its  fellows,  it  may  be  assumed  to  be  in  lateral  lesion. 
According  to  the  movements  that  are  possible  to  that  area  under 
the  stress  of  force,  there  may  be  two  kinds  of  lateral  lumbar 
lesions : 


1.  See  page  25.  line  17. 


OSTEOPATHIC  MECHANICS  97 

I.  A  subluxation,  an  immobilization  of  a  lumbar  vertebral 
articulation  in  the  position  of  sidebending. 

II.  A  traumatic  lesion,  an  immobilization  of  a  lumbar  verte- 
bral articulation  in  the  position  of  rotation.1 

It  has  been  proved  by  experiment,2  that  the  bodies  of  the 
lumbar  vertebrae  turn  to  the  concavity  of  the  curve  in  sidebending. 
Since  in  rotation  in  the  cervical  and  thoracic  areas  the  vertebral 
bodies  turn  to  the  concavity  of  the  curve,  the  same  holds  true  of 
the  traumatic  lesions  of  the  lumbar  area.  If  in  both  lesions  the 
bodies  of  the  vertebras  turn  to  the  same  side,  the  anatomical  rela- 
tions of  the  vertebra  in  lesion  are  practically  the  same  as  in  a 
thoracic  rotation  lesion,3  aside  from  the  relation  of  the  planes  of 
the  articulating  surfaces,4  the  pathological  effects  in  ligaments 
and  surrounding  tissues,5  and  the  obvious  fact  that  in  rotation  a 
vertebra  turns  in  a  larger  arc  than  in  sidebending-rotation, 
wherein  rotation  is  secondary;  hence  the  lumbar  spinous  process 
is  not  deviated  from  the  median  line  as  far  as  the  thoracic  spinous 
process  in  a  rotation  lesion. 

EXPERIMENTAL  PALPATION,  E. — -B  is  assumed  to  have  a  right 
lateral  lesion  of  the  third  lumbar  vertebra.  He  is  asked  to  sit 
erect  upon  the  end  of  the  table.  0  standing  behind  him  observes 
that  the  spinous  process  of  the  third  is  lateral  to  the  right  in  com- 
parison with  the  contiguous  spinous  processes.  If  his  muscular 
tissues  are  so  thick  that  the  line  of  processes  may  not  be  easily 
seen,  he  may  be  asked  to  bend  forward  in  moderate  flexion.  The 
spinous  process  of  the  second  or  the  first  may  be  found  lateral  to 
the  left.  B  is  asked  to  bend  sidewise  to  the  right  and  to  the  left. 
It  may  be  observed  that  lateral  flexion  is  more  easily  accomplished 
to  the  left  than  to  the  right. 

1.  See  page  11,  paragraph  5. 

2.  See  experiment  VI,  page  28;  also  figure  7,  page  27. 

3.  See  page  88,  paragraph  2. 

4.  See  page  15,  figure  I.     Since  rotation  is  not  normal  to  the  lumbar  area, 
save  in  cases  having  an  anomalous  fifth,  the  inferior  articular  facets  of  which 
face  less  medially  and  more  backward,  rotation  would  jam  the  planes  of  the 
articular  surfaces.     Dr.  Kendall  L.  Achorn  of  Boston  has  brought  to  my 
attention  several  sacra  in  which  the  superior  articular  facets  show  wide  devia- 
tions from  the  lumbar  type.     In  the  individual  whose  facets  are  like  those  of 
the  thoracic  articulations,  only  reverse  in  direction,  rotation  in  the  lumbo- 
sacral  joint  would  be  normal.     In  traumatic  lesions  of  this  area,  the  spinous 
process  of  the  lesioned  vertebra  is  usually  found  approximated  to   the  one 
below,  separated  from  the  one  above. 

5.  Necessarily  greater  in  traumatic  lesions  due  to  the  secondary  effects 
of  the  violent  wedging  of  the  vertebra  by  a  force  applied  in  a  direction  physio- 
logic-ally abnormal  to  the  joint. 


98  OSTEOPATHIC  MECHANICS 

O  stands  to  the  left  and  slightly  in  front  of  B,  places  his  left 
hand  on  top  of  B's  right  shoulder,  his  right  hand  against  the  left 
side  of  the  row  of  lumbar  spinous  processes  to  palpate  the  changes 
that  may  take  place  upon  movement  in  that  area.  O  now  bends 
B  sidewise  to  the  right  by  pulling  downward  upon  his  right  shoulder. 
At  the  same  time  he  observes  that  the  first  lumbar  spinous  process 
moves  to  the  left  of  the  second,  the  second  to  the  left  of  the  third; 
the  third  remains  stationary  in  regard  to  the  fourth  and  they 
together  move  to  the  left  of  the  fifth. 

By  moving  his  left  hand  to  a  place  behind  B's  right  scapula, 
it  will  be  possible  to  bend  B  forward  in  flexion,  and  then  by  push- 
ing with  his  left  shoulder  against  B's  chest  O  may  carry  him 
backward  in  extension.  By  palpating  with  the  forefinger  of  the 
right  hand  between  the  spinous  processes  of  the  third  and  fourth, 
O  may  find  that  no  motion  in  the  third-fourth  joint  is  manifest. 

By  reversing  his  position  to  the  right  and  front  of  B,  and 
placing  his  right  hand  upon  B's  left  shoulder,  he  may  bend  him 
in  left  lateral  flexion.  It  will  be  observed  that  the  lumbar  spinous 
processes,  each  in  turn,  move  to  the  left  of  the  one  below  except 
the  third  which  remains  immovable  in  relation  to  the  fourth. 

EXPERIMENTAL  PALPATION,  F. — Let  B  lie  upon  his  left  side 
upon  the  table,  O  standing  beside  the  table  facing  him.  0  asks 
B  to  place  the  left  leg,  the  one  underneath,  backward  upon  the 
table.  He  asks  him  to  flex  his  right  knee  and  place  the  right  leg 
in  advance  of  the  left.  A  partial  concavity  then  appears  upper- 
most at  B's  waistline.  To  complete  the  position  of  sidebending, 
O  may  place  beneath  B's  left  shoulder  a  large,  hard  pillow,  or  the 
thickness  of  his  forearm  beneath  the  upper  part  of  B's  thorax. 
Since  lateral  lumbar  lesions  are  produced  usually  by  strain  in 
sidebending-rotation,  the  movement  may  be  accomplished  with 
sidebending  by  position  and  rotation  by  movement. 

B  is  then  asked  to  place  his  right  arm  over  O's  right  shoulder, 
while  O  places  his  right  shoulder  against  the  forward  part  of  B's 
right  shoulder  or  in  his  axilla.  O  places  the  finger  of  his  left  hand 
against  the  under  side  of  the  lumbar  spinous  processes  to  palpate 
for  motion  in  those  articulations.  By  pressing  against  B's  shoul- 
der, O  may  rotate  B's  trunk  backward  toward  the  right.  It  will 
be  found  that  each  spinous  process  in  turn  moves  slightly  to  the 
left  of  the  one  below,  until  the  third  is  reached,  when  it,  being  in 
lateral  lesion  upon  the  fourth,  does  not  move  except  as  the  fourth 
moves,  as  one  vertebra  instead  of  two,  to  the  left  of  the  fifth  spinous 
process. 

In  some  people,  who  are  more  flexible  than  others,  sidebending 
is  possible  as  high  as  the  eighth  or  ninth  dorsal,  and  in  the  detection 


OSTEOPATHIC  MECHANICS  99 

of  lesion,  this  palpation  may  be  used  for  lower  thoracic  lesions. 

Particular  attention  should  be  paid  to  the  second-third  arti- 
culation when  the  spinous  process  of  the  second  has  appeared  to 
be  to  the  left  of  the  median  line  of  the  back,  for  there  is  present 
with  rare  exception  a  secondary  lesion  of  a  vertebra  above  and 
that  lesion  has  the  characteristic  that  distinguishes  it  from  a 
primary  lesion,  normal  movement. 

Lateral  lumbar  lesions  are  commonly  the  result  of  strain1  in 
a  return  to  the  upright  position  after  lateral  or  forward  flexion, 
as  in  the  lifting  of  heavy  objects.  Other  strains  are  the  lifting 
of  large  or  heavy  objects  above  the  head,  the  effort  in  falling  to 
save  oneself,  and  the  carrying  of  heavy  weights  at  the  side.  The 
causes  that  have  been  mentioned,  irritation  causing  muscular  con- 
traction, trauma,  and  infection,  produce  lumbar  lesions  with  great 
frequency. 

The  most  common  cause  for  lumbago  is  a  lateral  lumbar 
lesion.2  The  patient  gives  the  history  of  having  stooped  to  pick 
up  something  and  in  rising  of  having  been  seized  with  a  sudden 
pain  in  his  back  with  inability  to  move.  Careful  questioning  will 
elicit  the  fact  that  the  movement  was  one  of  sidebending. 

CORRECTIVE  MOVEMENTS 

THE  PRINCIPLE  OF  CORRECTION  FOR  LATERAL  LUMBAR  LESIONS 
IS  SIDEBENDING-ROTATION. 

GENERAL  RULES. — SINCE  SIDEBENDING  is  ALWAYS  ACCOM- 
PANIED BY  ROTATION  A  LATERAL  LUMBAR  LESION  MAY  BE  CORRECTED 
BY  PLACING  THE  PATIENT  IN  THE  POSITION  OF  SIDEBENDING  AND 
USING  THE  MOVEMENT  OF  ROTATION  FOR  ADJUSTMENT. 

Lumbar  sidebending  is  normal  alike  in  the  erect  and  hyper- 
extended  positions,  therefore,  lateral  lumbar  lesions  may  be 
corrected  with  the  patient  in  the  position  of  hyperextension. 


1.  It  should  not  be  forgotten  that  the  lumbar  area  supports  the  body 
above  and  that  the  influence  of  the  weight  would  be  felt  to  a  greater  degree 
upon  slight  strain  among  the  lumbars  than  elsewhere  in  the  spine. 

2.  Lateral  lumbar  lesions  are  also  etiologic  in  causing  constipation  of  the 
large  intestine,  pelvic  diseases,  pain  in  the  knee  not  caused  by  local  pathology, 
weak  ankles,  and  reflex  conditions  primarily  induced  by  lumbar  lesions.     See 
Marion  E.  Clark's  "Applied  Anatomy,"  pages  241-296,  published  by  the 
Journal  Printing  Co.,  Kirksville,  Mo.,  1906. 


100 


(  ISTKOPATHIC  MECHANICS 


FIG.  38. — Illustrating  the  sidebending  rolling  movement  for  the  correction  of  a  right 
lateral  lumbar  lesion. 


It  is  well  to  have  in  mind  the  compression  of  the  disc  on  the 
side  toward  which  the  vertebral  body  has  rotated  so  that  in  cor- 
rection one  may  seek  to  stretch  that  side  of  the  disc  and  compress 
the  side  that  was  widened  by  the  sidetilting  of  the  vertebra.1 

VIII.  SIDEBEND  ROLLING  MOVEMENT. — Let  B  be  assumed 
to  have  a  right  lateral  third  lumbar  lesion.  He  is  placed  upon 
the  table  in  the  position  described  in  experimental  palpation,  F.2 
O  places  the  elbow  of  his  left  arm  strongly  against  B's  right  hip, 
a  finger  of  the  left  hand  underneath,  to  the  left  of,  the  spinous 
process  of  the  fourth  lumbar  vertebra  to  make  of  it  a  fixed  point. 
O  may  place  the  tip  of  another  finger  between  the  spinous  processes 
of  the  fourth  and  fifth,  on  the  left  side  of  these  processes,  for  the 
purpose  of  determining  when  the  rotation  that  is  given  by  pushing 
against  B's  right  shoulder  is  sufficient  to  bring  the  force  of  sec- 
ondary rotation  to  the  third-fourth  articulation.  By  this  means 
the  osteopathist  may  often  get  an  idea  of  how  much  of  a  certain 

1.  The  structural  relations  must  be  kept  vividly  in  mind  while  execution 
is  planned.     There  should  be  no  uncertain  manipulation  of  soft  tissues  or 
attempt  at  motion  without  a  definite  action  in  mind. 

2.  See  page  98,  paragraph  4. 


OSTEOPATHIC  MECHANICS  101 

movement  is  required  to  bring  definite  action  upon  an  articulation. 
O  then  rotates  B  backward,  toward  B's  right,  until  he  knows  that 
relaxation  has  been  secured  about  the  joint  needing  adjustment, 
when  with  a  slight  additional  force  in  rotation  and  in  making  more 
fixed  the  fulcrum  below,  correction  is  accomplished.  It  is  common 
to  hear  the  popping  sound  in  the  correction  of  these  lesions  but 
it  should  be  remembered  that  the  movement  falls  short  of  adjust- 
ment unless  it  is  continued  a  step  beyond  the  amount  of  correc- 
tion secured  at  the  moment  the  popping  report  is  made.1 

This  movement  will  adjust  lateral  lesions  of  any  vertebra 
from  the  ninth  thoracic  to  the  fifth  lumbar  inclusive.  In  the 
lower  thoracic  region  sidebending  occurs  more  often  than  rotation 
in  the  movement  of  that  area  of  the  spine. 

IX.  HYPEREXTENSION   SIDEBENDING   MOVEMENT. — Let   B, 
having  the  same  lesion  as  above,  sit  upon  a  stool  of  moderate  height. 
O  stands  in  front  of  him  and  to  his  left.     O  reaches  around  B  to 
take  a  firm  hold  of  his  trunk  so  that  he  may  carry  him  back  in 
slight  hyperextension.     He   makes  the  necessary  sidebending  to 
the  right,  which  by  position  is  essential  to  correction;    he  then 
follows  sidebending  with  rotation  to  the  right.     Traction  is  often 
used  with  this  movement  and  precedes  sidebending.     Experience 
in  the  sensations  from  muscles,  tendons,  and  joints,  is  necessary 
to  the  successful  use  of  this  movement  for  adjustment  of  a  parti- 
cular lesion  for,  with  the  arms  about  the  patient  lifting  him,  there 
is  no  opportunity  to  employ  a  fixed  point  and  in  consequence  of 
this  lack  of  localization,  there  may  be  indiscriminate  movement 
of  lumbar  joints  with  many  popping  sounds  and  without  securing 
adjustment  of  the  third-fourth  lesion. 

X.  KNEE-BENDING  MOVEMENT. — B  is  assumed  to  have  a 
right  lateral  lesion  of  the  fifth  lumbar  vertebra.     He  is  asked  to 
sit  upon  a  stool  of  moderate  height,  while  O  kneels  upon  his  right 
knee  to  the  right  of  B.     O  passes  his  right  arm  across  B's  chest 
under  his  left  arm  and  lays  his  hand  over  B's  left  ribs.     Reaching 
across  B's  back,  he  grasps  the  anterior  superior  spine  of  B's  left 
innominate  to  hold  the  pelvis  immobile.     0  asks  B  to  bend  his 
body  sidewise  over  O's  back  and  lay  his  arms  outstretched  in 
advance  of  his  body.     By  pulling  with  his  right  arm  and  holding 
the  pelvis  fixed  with  his  left,  0  rotates  B's  torso  to  the  right,  in 
secondary  rotation,  several  times  in  gradually  increasing  arcs  until 


1.  It  is  regrettable  that  so  many  osteopathists  have  not  followed  more 
closely  the  many  experiments  of  Dr.  Carl  McConnell  so  that  the  popping 
sound  and  its  secondary  effects  are  well  understood.  The  reader  is  urged  to 
read  Dr.  McConnell's  own  words  upon  this  subject,  in  the  Journal  of  the  A.  O. 
A.,  May,  1913,  page  547. 


102  OSTEOPATHIC  MECHANICS 

he  is  conscious  that  B  understands  the  direction  of  the  movement 
and  has  relaxed  sufficiently  to  make  adjustment  possible  by  further 
increase  of  rotation. 

One  may  by  placing  the  finger  or  thumb  against  the  left  side 
of  any  lumbar  vertebra,  make  a  fixed  point  against  which  one  may 
adjust  a  sidebending  lesion  of  the  vertebra  above. 

AFTER-TREATMENT 

Since  the  mass  of  muscles  in  the  lumbar  area  is  the  largest  of 
the  back,  it  is  essential  that,  after  the  unbalance  resulting  upon 
lesion,  effort  should  be  made  to  secure  a  restoration  to  normal 
action  in  these  muscles;  for  this  reason  movements  that  will 
exercise  both  groups  equally1  should  be  taken  for  some  time  and 
the  patient  not  dismissed  until  the  physician  has  noted  a  return  to 
power  of  all  the  atonic  fasciculi. 

All  movements  that  tend  toward  sidebending  to  the  side 
opposite  the  former  position  of  the  spinous  process  should  be 
avoided ;  leaning  to  the  same  side,  taken  as  a  conscious  effort  and 
with  some  resistance,  will  hasten  the  process  of  muscle  building. 
Upward  reaching  with  the  hand  upon  that  side  must  be  avoided 
also,  for  a  concavity  to  the  opposite  side  would  be  produced  and 
a  possible  recurrence  of  the  lesion  follow. 

At  each  treatment  the  joint  should  be  put  through  its  normal 
movements  as  far  as  possible  and  especially  following  correction 
for  the  reason  that  ligamentous  tissues  are  directly  acted  upon  in 
this  way.  Preceding  correction,  flexion  and  extension  will  often 
help  to  secure  the  relaxation  so  often  helpful  to  a  ready  adjust- 
ment of  the  lesion. 

SIDEBENDING   LESIONS 

When  sidebending  is  normal  to  the  thoracic  area,  it  has  been 
demonstrated,2  it  follows  forward  flexion  and  the  bodies  of  the 
vertebra?  rotate  to  the  convexity  of  the  curve.  According  to  the 
definition3  of  a  subluxation,  a  sidebending  lesion  of  a  thoracic 

1.  For  example,  backward  bending,  forward  flexion,  and  upward  reaching 
with  both  arms. 

2.  See  page  28,  experiment  IX. 
•'i.  See  page  11,  line  17. 


OSTEOPATHIC  MECHANICS 


103 


vertebra  may  be  defined  as  an  immobilization  of  that  vertebra  in 
the  position  of  primary  forward  bending  and  secondary  lateral 
flexion.  When  a  superior  sidebending  force  is  directed  against 
an  almost  defenseless  articulation  in  the  position  of  erectness  or 
hy perextension,  a  lateral  lesion  of  that  vertebra  may  result  and 
from  the  character  of  its  production  it  may  be  classified  as  a  trau- 
matic lesion. 

It  is  altogether  due  to  the  character  of  the  intervertebral 
disc  that  in  sidebending-rotation  the  bodies  of  the  vertebrae  rotate 


FIG.  39. — Schematic  drawing  to  illustrate  a  sidebending  lesion  of  the  third  thoracic  to 
the  left.  The  arrows  indicate  the  direction  in  which  the  spinous  process  points.  The  heavy 
line,  the  right  prominent  transverse  process.  The  light  line,  the  slightly  anterior  transverse 
process  of  the  third.  The  horizontal  lines,  the  transverse  processes  of  the  second  and  fourth. 
The  vertical  line,  the  median  line  of  vertebral  bodies.  The  curved  lines,  the  concavity  and 
convexity  of  the  original  curve  produced  by  sidebending  to  the  left. 


away  from  the  side  to  which  bending  takes  place.  As  has  been 
explained  in  the  discussion  of  the  general  movement  of  sidebend- 
ing,1 the  intervertebral  disc  has  already  been  compressed  anter- 
iorly; when  sidebending  follows,  there  is  but  one  direction  in  which 
rotation  of  the  vertebra  is  possible  and  that  is  away  from  further 
compression.  The  character  of  the  disc  is  responsible  for  the 
same  rotation  in  a  traumatic  lesion.  Substances  that  are  highly 

1.  See  page  29,  paragraphs  one  and  three. 


104  OSTEOPATHIC  MECHANICS 

elastic  rotate  their  mass  and  adjoining  movable  structures  away 
from  the  constricting  force  in  the  pathway  of  least  resistance. 

These  lesions  are  ordinarily  produced  as  the  result  of  strain 
in  the  position  of  forward  flexion  with  sidebending  in  the  effort 
to  pick  up  a  heavy  object;  in  dodging  a  missile  with  a  concluding 
sharp  movement  laterally,  or  by  direct  injury;  more  rarely  by  the 
other  causes  operative  in  the  production  of  most  lesions. 

These  lesions  are  spoken  of  as  lateral  thoracic  lesions,  in 
centra-distinction  to  the  rotation  lesions  of  the  same  area.  They 
are  named  according  to  the  direction  toward  which  the  spinous 
process  points.  A  left  lateral  third  thoracic  would  be  named  from 
the  spinous  process  of  the  third  being  to  the  right  of  the  median 
line  of  spinous  processes.  The  anatomical  relations  of  such  a 
lesion  would  be  as  follows: 

1.  Spinous  process  of  the  third  lateral  to  the  left. 

2.  Vertebral  body  rotated  to  the  right. 

3.  The  right  transverse  process  more  prominent  posteriorly 
than  the  adjacent  transverse  processes,  separated  from  the  fourth 
and  approximated  to  the  second. 

4.  The  left  transverse  process  less  prominent  than  the  adjoin- 
ing transverse  processes,  approximated  to  the  fourth  and  separated 
from  the  second. 

6.  The  intervertebral  disc  compressed  upon  the  left,  widened 
upon  the  right. 

6.  The  right  third  rib  slightly  posterior  to  adjacent  ribs, 
separated  from  the  fourth  and  approximated  to  the  second. 

7.  The  left  third  rib  slightly  anterior  to  adjacent  ribs,  approxi- 
mated to  the  fourth  and  separated. from  the  second. 

8.  A  perpendicular  line  projected  upward  from  the  superior 
surface  of  the  vertebral  body,  inclined  to  the  left. 

9.  Intervertebral  foramen  on  the  left  narrowed  antero-poster- 
iorly,  on  the  right  widened  vertically. 

10.  Ligamentous  changes. — On  the  right  the   anterior  longi- 
tudinal, lateral  spinal,  capsular,  and  flava  ligaments  are  stretched 
and  atrophied;   on  the  left  thesame  ligaments  are  shortened  and 
thickened. 

11.  Fasciculi  of  the  multifidus  and  rotatores  are  stretched 
and  atrophied  on  the  right;  fasciculi  of  the  same  muscles  shortened 
and  thickened  on  the  left. 

EXPERIMENTAL  PALPATION,  G. — Let  the  patient,  B,  sit  upon 
a  stool  of  moderate  height,  with  the  back  exposed  to  inspection. 
If  he  has  a  lateral  lesion  of  the  third  thoracic  vertebra,  the  spinous 


OSTEOPATHIC  MECHANICS  105 

process  of  that  vertebra  will  be  found  to  be  slightly  out  of  aline- 
ment  with  the  ones  above  and  below,  not  markedly  deviated  to  the 
side  but  sufficiently  out  of  alinement  to  be  noted  upon  close 
inspection.  B  is  asked  to  bend  forward  in  slight  flexion  and  then 
to  sidebend  his  head  and  shoulders  to  the  right  and  to  the  left. 
If  the  lesion  is  a  right  lateral  third  thoracic,  it  will  be  found  that 
sidebending  is  more  easily  accomplished  to  the  right  than  to  the 
left  for  the  reason  that  in  sidebending  the  bodies  of  the  vertebrae 
rotate  to  the  convexity  of  the  curve,  hence  bending  away  from  the 
convexity  is  always  much  more  easily  done. 

O  should  now  place  his  finger-tips  between  the  spinous 
processes  of  the  third  and  fourth  and  the  second  and  third  for  the 
purpose  of  palpating  for  mobility  in  those  articulations.  The 
patient's  head  should  be  moved  backward  and  forward  in  flexion 
and  extension.  If  lesion  is  present,  there  will  be  restricted  motion 
between  the  spinous  processes  of  the  third  and  fourth  vertebrae. 
The  finger-tips  should  then  be  placed  to  the  right  of  the  spinous 
processes  of  the  second,  third,  and  fourth  thoracic  vertebras  to 
detect  movement  of  these  in  sidebending  to  the  right.  If  lesion 
is  present  in  the  third-fourth  articulation,  there  will  be  no  change 
in  the  relative  positions  of  these  upon  movement.  Sidebending 
to  the  left  should  elicit  the  same  results.  If  secondary  lesion 
above  or  below  should  be  present,  it  would  show  practically  no 
disturbance  in  motion.1  These  lesions  will  be  of  the  same  type  as 
the  primary  lesion,  thus,  a  primary  sidebending  lesion  will  induce 
a  secondary  sidebending  lesion.2 

Differential  diagnosis  must  be  made  from  a  rotation  lesion  of 
the  same  vertebra  and  is  made  with  great  difficulty  in  persons  who 
are  obese  or  well  covered  with  heavy  spinal  musculature.  The 
objective  signs  are  alike  in  that  there  is  a  deviation  of  the  spinous 
process  to  the  right,  let  us  say,  of  the  median  line.  The  deviation 
is  usually  less  in  a  lateral  lesion  than  in  a  rotation  lesion.  By  three 
means  may  we  differentiate: 

1.  History. — The  patient  may  be  able  to  recall  the  time  of 
the  production  of  the  lesion.     If  it  was  the  result  of  a  sidebending 
force  of  great  intensity,  unquestionably  the  lateral  lesion  is  a 
traumatic  one.     If  it  was  produced  by  sidebending  in  the  position 
of  forward  flexion,  the  diagnosis  should  be  considered  as  estab- 
lished in  the  absence  of  more  pronounced  signs. 

2.  Palpation. — In  a  right  rotation  lesion,  the  prominent  left 


1.  See  page  17,  line  35,  also  page  18,  line  1. 

2.  Cf.  page  89,  line  paragraph  5. 


106  OSTEOPATHIC  MECHANICS 

third  transverse  process  and  the  corresponding  rib  are  approxi- 
mated to  the  fourth  and  separated  from  the  second.  1 

In  a  right  sidebending  lesion,  the  prominent  left  third  trans- 
verse process  and  corresponding  rib  are  separated  from  the  fourth 
and  approximated  to  the  second.2 

3.  Therapeutic  measures. — -When  following  preliminary 
means  of  securing  relaxation,  the  proper  adjustive  method  of 
correction  is  applied  for  a  rotation  lesion  and  it  fails  to  overcome 
the  lesion,  the  corrective  movements  for  a  lateral  third  dorsal 
may  be  attempted  with  judgment  and  carefulness.s 

A  lateral  lesion  may  need  to  be  differentiated  from  a  spinal 
anomaly,  a  vertebra  having  a  deflected  spinous  process.  In  the 
latter  case,  motion  will  be  found  to  be  present  in  the  articulations 
of  which  that  vertebra  forms  a  part.  In  the  case  of  a  lateral 
lesion  to  the  right  with  a  spinous  process  deflected  to  the  left  and 
in  line  or  out  of  line  with  adjoining  vertebral  spinous  processes, 
by  the  means  mentioned  above  may  diagnosis  be  determined. 
Such  cases  are  the  most  difficult  ones  to  diagnose  and  may  need 
the  skill  of  an  experienced  osteopathist.4 

CORRECTIVE  MOVEMENTS 

THE  PRINCIPLE  OF  CORRECTION  FOR  LATERAL  THORACIC 
LESIONS  IS  SIDEBENDING  IN  FORWARD  FLEXION  TO  THE  SIDE 
OPPOSITE  THE  LESION. 

GENERAL  RULES. — SINCE  SIDEBENDING  is  A  PART  OF  THE 

COMPOUND  MOVEMENT  OF  SIDEBENDING-ROTATION,  LATERAL  THO- 
RACIC LESIONS  MAY  BE  CORRECTED  BY  PLACING  THE  PATIENT  IN 


1.  Reversing  experiment  I,  page  23,  when  the  subject,  B,  is  rotated  to 
the  left,  a  curvature  will  be  seen  in  his  thoracic  spinal  area  with  the  convexity 
to  the  right,  the  high  side  upon  the  left;  therefore,  in  a  single  lesion,  e.  g.,  a 
right  rotation  lesion  of  the  third,  the  left  side  will  be  the  counterpart  of  the 
concavity  of  the  original  curve  in  the  production  of  the  lesion. 

2.  Experiment  IX,  page  28,  presents  the  fact  that  when  the  spinous  pro- 
cess points  toward  the  concavity  of  the  curve,  the  body  of  the  vertebra  has 
rotated  toward  the  left,  the  convexity  of  the  curve.     The  transverse  process 
on  that  side  would,  naturally,  be  separated  from  its  fellow  below.     See  page 
29,  paragraph  1. 

3.  Palpation  is  the  preferred  method  of  differentiation.  It  is  rare  that  by 
the  histories  of  these  cases  can  their  diagnoses  be  made.     The  objection  to  the 
third  means  is  that  it  has  its  dangers  in  the  hands  of  any  but  watchful  physi- 
cians. 

4.  Dr.  C.  P.  McConnell,  in  the  Journal  of  the  A.  O.  A.,  Feb.  1913,  page 
355,  pertinently  remarks  that  the  biggest  problem  in  technique  is  careful 
diagnosis.     The  entire  article  should  be  read. 


OSTEOPATHIC  MECHANICS 


107 


FIG.  40. — Illustrating  the  head-bending  movement  for  the  correction  of  a  right  lateral 
third  dorsal  lesion. 


THE    POSITION    OP    FLEXION-SIDEBENDING    AND    USING   THE    MOVE- 
MENT OF  ROTATION  FOR  ADJUSTMENT. 

XI.  HEAD-BENDING  MOVEMENT. — B  is  assumed  to  have  a 
right  lateral  lesion  of  the  third  thoracic.  B  is  asked  to  lie  upon  his 
right  side  on  the  table.  O  places  his  left  forearm  under  B's  head, 
his  hand  encircling  B's  neck.  He  places  the  thumb,  a  finger,  or  a 
knuckle,  underneath,  to  the  right  side  of,  the  spinous  process  of 
the  third  to  pull  it  toward  the  left.  B's  head  is  carried  forward 
in  slight  flexion,  his  face  turned  to  the  right.  1  O  then  sidebends 

1 .  The  purpose  of  the  turning  of  the  face  is  to  distinguish  this  movement 
from  the  head-leverage  movement,  I,  page  91.  The  students  have  a  memory 
scheme  for  the  correcting  of  these  lesions  which  reads,  "In  rotation  lesions, 
turn  the  face  and  bend  the  head  to  the  same  side  as  the  spinous  process;  in 
sidebending  lesions,  turn  the  face  toward  the  spinous  process  and  bend  the 
head  to  the  opposite  side." 

Turning  the  face  toward  the  spinous  process  at  least  turns  the  bodies  of 
the  cervical  vertebrae  above  in  the  direction  it  is  desired  to  turn  the  body  of  the 
vertebra  in  lesion.  I  am  not  persuaded  that  it  is  of  particular  mechanical 
value  unless  the  lesion  be  of  the  first  thoracic. 


108  OSTEOPATHIC  MECHANICS 

B's  head  to  the  left,  at  the  same  time  bringing  stress  against  the 
spinous  process  in  the  effort  to  turn  the  vertebral  body  from  the 
left  toward  the  right.  When  relaxation  has  been  secured,  an 
increase  of  force  will  usually  adjust  the  lesion.  If  the  popping 
sound  is  heard,  the  sidebending  must  be  carried  slightly  further. 

XII.  STOOL-AND-ARM  MOVEMENT. — Let  B,who  is  assumed  to 
have  the  same  lesion  as  in  movement  XI,  sit  upon  the  table,  O  si  and- 
ing  upon  his  right  side.     O  places  his  right  axilla  over  B's  right 
shoulder,  his  forearm  along  the  side  of  B's  head,  his  right  hand 
on  the  top  of  B's  head.     He  bends  B's  head  in  slight  forward 
flexion,  and  then  turns  it  toward  the  right,  and  sidebends  it  slightly 
to  the  left.     He  places  the  thumb  of  his  left  hand  against  the  right 
side  of  the  spinous  process  of  the  third  and  pushes  it  toward  the 
left  at  the  same  time  bending  B's  head  to  the   left  in   greater 
lateral  flexion.     He  repeats  this  movement  several  times.     The 
moment  B  becomes  accustomed  to  the  movement  of  sidebending 
so  that  he  relaxes  perfectly,  both  pressure  against  the  spinous 
process  and  sidebending  should  be  increased  until  correction  is 
made. 

The  last  two  movements  will  correct  lateral  lesions  of  the 
upper  thoracic  vertebrae  from  the  first  to  the  fourth  inclusive. 

XIII.  LOCKED-ARMS  MOVEMENT. — B  is  assumed  to  have  a 
right  lateral  lesion  of  the  seventh  thoracic.     He  is  asked  to  sit 
upon  a  stool  of  moderate  height,  to  fold  his  arms  in  front  of  his 
chest,  and  to  rest  his  head  upon  his  arms,  with  his  face  turned  to 
the  right.     O  places  his  axilla  over  B's  left  shoulder,  passes  his 
left  arm  under  B's  folded  arms  and  grasps  B's  right  upper  arm. 
B  is  carried  forward  in  some  flexion,  O  bending  his  knees  if  neces- 
sary to  bring  his  chest  to  the  level  of  B's  head.     O  places  his  right 
thumb  against  the  left  side  of  the  spinous  process  of  the  eighth 
thoracic  vertebra  to  make  a  fixed  point  against  which  to  sidebend 
B's  seventh  thoracic  vertebra.     O  then  sidebends  B  to  the  left 
strongly,  and  repeats  the  movement  until  B  relaxes,  upon  which, 
with  an  increase  of  both  pressure  and  sidebending,  he  is  able  to 
adjust  the  lateral  seventh  vertebra. 

This  movement  may  be  varied  by  O's  placing  his  thumb  against 
the  right  side  of  the  spinous  process  of  the  seventh  to  add  rotation 
to  sidebending  of  the  vertebra  in  lesion.  This  may  be  changed 
by  having  O  stand  on  the  right  of  B  and  reverse  his  hands. 

The  above  movement  will  adjust  lateral  thoracic  lesions  from 
the  fifth  to  the  eighth  inclusive. 

XIV.  SHOULDER-DOWNWARD   MOVEMENT. — Let   B,    who   is 
assumed  to  have  a  right  lateral  ninth  thoracic  lesion,  sit  upon  a 


OSTEOPATHIC  MECHANICS  109 

stool,  with  0  standing  beside  him  to  the  right.  O  reaches  across 
B's  chest  and  grasps  his  left  shoulder,  at  the  same  time  placing  the 
thumb  of  his  left  hand  against  the  left  side  of  the  spinous  process 
of  the  tenth  thoracic  to  make  of  it  a  fixed  point.  O  then  bends  B 
forward  in  slight  flexion  and  then  to  the  left,  and  repeats  the  lateral 
flexion  until  B  is  felt  to  relax,  when  O  concludes  the  movement  of 
lateral  flexion  with  a  slight  amount  of  rotation  to  the  left  with 
increased  reinforcement  of  the  fixed  point.  Adjustment  should 
then  occur. 

XV.  SHOULDER-RAISING  MOVEMENT. — Let  B  sit  upon  the 
table,  with  his  feet  resting  upon  a  stool  so  that  he  will  relax  without 
a  fear  of  falling.  With  a  right  lateral  lesion  of  the  ninth  thoracic, 
O  should  stand  to  B's  right,  his  right  shoulder  in  B's  right  axilla. 
0  should  pass  his  right  arm  across  B's  chest,  under  his  left  axilla, 
with  his  hand  resting  upon  the  left  ninth  rib  at  the  angle.  B  bends 
forward  in  very  slight  flexion.  0  places  the  thumb  of  his  left 
hand  against  the  right  side  of  the  spinous  process  of  the  ninth  and 
pushes  toward  the  left,  at  the  same  time  raising  B's  right  shoulder 
and  sidebending  B  to  the  left,  concluding  the  sidebending  with 
secondary  rotation.  At  the  moment  of  relaxation,  increase  of 
pressure  upon  the  left  rib,  against  the  spinous  process,  and  side- 
bending-rotation  to  the  left  will  serve  to  adjust  the  lesion. 

The  last  two  movements  will  correct  lateral  lesions  of  the 
thoracic  vertebrae  from  the  sixth  to  the  ninth  inclusive: 


AFTER-TREATMENT 

Resistance  exercises1  are  of  the  utmost  importance  in  the 
maintenance  of  the  normalization  of  a  joint  that  has  been  in 
sidebending  lesion.  For  those  patients  who  have  had  lateral 
lesions  of  the  upper  thoracic  vertebrae,  the  resistance  exercises  must 
be  taken  in  the  position  of  extreme  forward  flexion  for  in  this  way 
there  is  a  natural  limitation  placed  upon  the  extent  of  the  side- 
bending,  localizing  it  to  the  area  desired.  Care  must  be  taken  in 
advising  all  exercises  that  the  patient  shall  have  no  opportunity 
to  misinterpret  the  directions  for  recurrence  is  far  too  frequent 
when  lesions  have  been  in  the  chronic  stage  for  months  or  years. 
The  force  of  habit  lies  in  the  small  muscle  fasciculi  and  it  requires 

1.  Much  of  that  which  has  been  said  of  the  after-treatment  of  rotation 
lesions,  pages  95  and  98,  may  with  some  revision  be  applied  to  lateral  lesions. 


110  OSTEOPATHIC  MECHANICS 

constant  vigilance  to  overcome  it.  While  sidebending  lesions  are 
almost  invariably  the  icsult  of  tiaumatism,  the  surrounding 
tissues  are  markedly  changed  in  their  potentiality.  This  must 
not  be  forgotten;  in  fact  the  complete  picture  of  the  lesion  should 
always  be  held  before  the  consciousness  when  treating  these 
lesions. 

Since  the  cervical  area  is  characterized  by  both  the  move- 
ments of  rotation  and  sidebending,  these  types  of  cervical  lesions 
should  under  ordinary  circumstances  be  discussed  in  the  same 
chapter  as  the  thoracic  and  lumbar  lesions  of  those  types;  it  is 
for  the  reason  that  in  the  osteopathic  treatment  of  patients  cervical 
lesions  are  of  almost  greater  importance  than  any  others,  that  it 
is  necessary  to  give  them  the  attention  of  a  separate  chapter. 


A  carefully  educated  sense  of  touch  is  the  keynote  to  both 
osteopathic  diagnosis  and  operative  technique.  From  the 
very  nature  of  the  osteopathic  conception,  the  physical 
body  viewed  as  a  mechanism  whose  disordered  or  dis- 
eased conditions  demand  anatomical  readjustment,  it  is 
imperative  that  a  delicate  and  educated  sense  of  touch  be 
acquired  to  order  to  apply  its  tenets  logically  and  success- 
fully.— "THE  PRACTICE  OF  OSTEOPATHY,"  McConnell  and 
Teall. 


OSTEOPATHIC  MECHANICS 


111 


CHAPTER  VI. 
CERVICAL  LESIONS 

The  cervical  region  is  the  most  interesting  area  of  the  spine 
because  it  is  in  relation  with  some  of  the  vital  structures  of  the 
human  body,  especially  the  superior  cervical  ganglia,  the  great 
relay  centres  for  sympathetic  fibres  to  the  head.  Mechanically 
speaking,  it  is  the  least  understood  area  of  the  spine.  Our  great 
anatomists  have  failed  to  comprehend  the  planes  of  the  articular 
surfaces  of  the  cervical  vertebrae.  Ernest  Frazer1  has  shown  by  a 
drawing  that  rotation  in  the  cervical  area  does  not  take  place 
about  a  central  axis  passing  through  the  body  of  the  vertebra 
but  he  has  not  gone  beyond  that  statement.  A  detailed  study  of 
the  planes  and  axes  should  precede  osteopathic  consideration. 

The  body  of  a  typical  cervical  vertebra,  the  fourth,  is  thinner 
than  the  body  of  a  thoracic  or  lumbar  vertebra.  Its  inferior  sur- 
face is  not  a  flat  surface,  being  concave  antero-posteriorly  and 


FIG.  41. — Drawing  of  the  sixth  cervical  vertebra  to  show  the  relations  of  anterior  and 
posterior  tubercles  and  articular  facets. 

1.  Loc.  cit. 


112  OSTEOPATHIC  MECHANICS 

one-third  less  deep  than  transversely  wide.  Its  anterior  margin 
projects  as  a  lip  over  the  superior  margin  of  the  fifth  vertebral 
body  below.  It  rests  upon  an  intervertebral  disc.  It  is  shallow 
in  comparison  with  the  discs  of  other  regions  and  is  wedge- 
shaped  with  the  base  of  the  wedge  anterior.  Due  to  the  shape  of 
the  discs  the  cervical  area  presents  a  physiological  curve,  convex 
anteriorly.  The  superior  surface  of  the  body  of  the  fifth  is  trans- 
versely concave  with  lateral  margins  projecting  upward,  like  lips, 
a  distance  of  a  quarter  of  an  inch.  With  the  lateral  margins 
of  the  inferior  surface  of  the  body  of  the  fourth  above,  they 
form  diarthrodial  joints,  the  gliding  of  the  inferior  surfaces 
being  almost  vertically  upward  and  downward  upon  the  inner 
margins  of  the  lips  of  the  fifth  below.1  It  should  now  be 
plainly  seen  that  rotation  about  a  central  axis  is  impossible.  Due 
to  the  elasticity  of  the  nucleus  pulposus,2  there  may  be  slight 
movement  between  the  bodies  in  any  cervical  articulation3  but 
not  like  that  of  the  thoracic  joint. 

The  roots  of  the  arch,  the  pedicles,  of  the  fourth  are  short 
and  spring  from  the  lateral  aspect  of  the  body.  The  laminae  are 
flat  and  long,  meeting  at  an  obtuse  angle  posteriorly,  from  which 
junction  projects  a  bifid  spinous  process  for  the  attachment  of 
extensor  muscles.  At  the  point  of  union  of  pedicles  and  laminae 
are  developed  the  articular  facets,  the  upper  one  projecting  upward, 
backward,  and  medially,  the  lower  one,  downward,  forward,  and 
outward.  If  the  articular  facets  were  considered  apart  from  the 
rest  of  the  vertebra,  in  the  matter  of  rotation,  the  axis  for  the 
inferior  facets  would  be  a  line  somewhere  in  the  front  part  of  the 
neck;  the  axis  for  the  superior  facts,  a  line  bisecting  the  external 
occipital  protuberance.  The  absurdity  of  such  a  proposition 
appears  on  the  face  of  it. 

The  transverse  processes  are  formed  of  two  parts,  springing 
from  the  body  anteriorly  and  from  the  arch  laterally,  united  by  a 
bridge  of  bone  which  forms  thereby  the  transverse  foramen  foi 

1.  Morris's  "Anatomy",  page  226,  last  paragraph. 

2.  Morris,  loc.  cit.,  page  226,  second  paragraph. 

3.  Osteopathically  considered,  the  cervical  area  is  divided  into  three 
parts,    the  atlanto-epistrophic  articulation;   the  articulations  of   the  epistro- 
pheus  and  third,  the  third-fourth,  and  the  fourth-fifth;  the  articulations  of  the 
fifth-sixth  and  the  sixth-seventh.     The  seventh  cervical  is  regarded  as  a 
thoracic  vertebra. 


OSTEOPATHIC  MECHANICS 


113 


To     9/*   t/ene 
To     10th 
To    /Zr/i 


To  External  Corof/ei 
—  Jo  Infernal  Carotid 


Gray  Ham/ 


~  To  Larynx 
—  To  Pharynx 

~   Super/or  Cardiac 


•f   Gray  Rymus 
To  Thyroid 
6    Gray  ffamus 
Middle  Cerdioc 

g  [  Gray  Ratni 
Inferior  Cord/etc 
Muscles 

FIG.  42. — Lateral  aspect  of  the  cervical  area  showing  the  transverse  processes  and  thei 
close  relationship  to  the  articular  facets  just  behind  them.  The  three  cervical  plexuses  of  the 
sympathetic  system  have  been  sketched  anterior  to  the  prevertebral  muscles  to  show  the  wide- 
reaching  effect  of  interference  by  lesion  upon  this  area. 


the  transmission  of  the  vertebral  artery  and  vein  and  a  sympathetic 
plexus  of  nerves.  The  anterior  part,  called  the  costal  process 
because  it  is  the  homologue  of  the  rib  in  the  thoracic  region,1 
shows  a  prominence  which  is  termed  the  anterior  tubercle. 

The  posterior  part  of  the  transverse  process  has  been  called 
the  posterior  tubercle.  It  projects  laterally  farther  than  the 
anterior  tubercle  and  its  posterior  surface  lies  in  a  horizontal  plane 
less  than  three-sixteenths  of  an  inch  in  front  of  the  upper  anterior 
margin  of  the  superior  articular  facet  of  the  vertebra  below.  If 
the  inferior  facet  were  to  glide  backward  upon  this  superior  facet, 
the  posterior  surface  of  its  posterior  tubercle  would  come  in  con- 
tact2 almost  instantly  with  the  surface  of  the  superior  facet  above 


1.  Gray's  "Anatomy,"  page  50,  paragraph  2. 

2.  I  am  indebted  to  my  student,  Mr.  George  Eddy  of  the  January,  1917, 
class,  for  a  thorough  dissection  of  the  cervical  spinal  area.     Mr.  Eddy  found 
that  when  the  coverings  of  bone  and  the  muscles  were  deducted  from  the  three- 
sixteenths  of  an  inch  noted  above  there  remained  but  one-sixteenth  of  an  inch 
of  space  through  which  the  inferior  facet  might  glide  backward.     It  is  my 
opinion  that  osteopathists  have  not  given  enough  attention  to  the  relation  of 
these  bony  processes  in  the  consideration  of  cervical  lesions. 


114 


OSTEOPATHIC  MECHANICS 


mentioned,  thus  again  proving  that  rotation  does  not  take  place 
upon  a  central  or  an  oblique  axis. 

The  osteopathist  has  at  his  command  the  means,  palpation,1 
of  demonstrating  that  the  axis  of  motion  in  cervical  rotation  is  a 
line  perpendicular  to  the  surface  of  the  superior  articular  facet  of 
the  lower  of  the  two  vertebra  in  each  articulation  of  the  side 
toward  which  rotation  is  made.  The  axis  of  motion  differs  among 
the  different  cervical  articulations  for  the  reason  that  as  the 
cervical  area  merges  into  the  thoracic,  the  articular  surfaces  come 
to  resemble  those  of  the  adjacent  region.  The  lower  cervical  area 
is  characterized  by  sidebending,  while  the  upper  cervical  area  is 
characterized  by  rotation. 

The  lesions  of  the  cervical  region  are  usually  rotation  or  side- 
bending  lesions  and  from  the  prominence  of  the  anterior  tubercle 
of  the  transverse  process  of  the  vertebra  in  lesion,  the  lesion  has 
been  named  "anterior  on  the  right"  or  " anterior  on  the  left." 
A  third  cervical  anterior  on  the  right  may  be  defined  as  a  lesion 
in  which  the  thiid-fourth  cervical  articulation  is  immobilized  in 
the  position  of  rotation  to  the  left.  A  sixth  cervical  anterior  on 


FIG.  43. — Drawing  to  represent  the  right  lateral  view  of  a  right  anterior  third  cervical 
lesion. 


1.  Experiment  V,  page  26. 


OSTEOPATHIC  MECHANICS  115 

the  right  is  a  lesion  in  which  the  sixth-seventh  articulation  is 
immobilized  in  the  position  of  sidebending  to  the  left.1 

The  relation  of  the  anatomical  structures  in  such  a  lesion 
would  be: 

1.  Spinous  process  to  the  right.2 

2.  The  right  anterior  tubercle  of  the  transverse  process  of  the 
third  in  advance  of  the  anterior  tubercles  of  the  second  and  fourth. 

3.  The  left  anterior  tubercle  of  the  transverse  process  of  the 
third  very  slightly  posterior  in  the  line  of  left  anterior  tubercles 
which  is  not  usually  apparent  upon  palpation. 

4.  The  vertebral  body  of  the  third  rotated  toward  the  left 
slightly  with  secondary  sidetilting  upward  upon  the  right  and 
downward  upon  the  left. 

5.  Intervertebral  disc  compressed  upon  the  left,  stretched 
and  widened  upon  the  right. 

6.  Axis  of  motion,  a  line  perpendicular  to  the  left  superior 
articular  facet  of  the  fourth  cervical  vertebra. 

7.  Intervertebral  foramen  on  the  left  narrowed,  on  the  right 
widened  vertically. 

8.  Ligamentous   changes. — The    right    capsular    and    flava 
stretched;    the  right  halves  of  the  anterior  and  posterior  longi- 
tudinal stretched,  the  left  halves  relaxed. 

9.  Muscles. — The  right  third-fourth  intertransversarii  stretch- 
ed; fasciculi  of  the  scaleni  anterior  and  medius,  levator  scapulae , 
and  splenius  cervicis  attached  to  the  right  transverse  process  of 
the  third  cervical  vertebra,  stretched. 

EXPERIMENTAL  PALPATION,  G. — The  patient,  B,  is  assumed 
to  have  a  right  anterior  third  cervical.  According  to  the  manner 
of  palpation  in  experiment  V,  page  26,  let  the  radial  border  of  the 
index  finger  of  each  hand  rest  upon  the  anterior  tubercles  of  the 
second,  third,  and  fourth  transverse  processes,  to  note  any  differ- 
ence that  may  exist  among  them.3  If  the  third  on  the  right  is  in 
lesion,  the  anterior  tubercle  of  that  vertebra  will  be  markedly  in 
advance  of  the  second  and  fourth  tubercles  and  also  in  advance 
when  compared  with  the"  left  anterior  tubercle  of  the  third.  When 
the  prominence  of  this  tubercle  has  been  determined,  the  functional 

1.  Experiment  VII,  page  28. 

2.  In  the  earlier  literature  of  osteopathy,  these  lesions  were  called  lateral 
lesions,  named  according  to  the  side  toward  which  the  spinous  process  seemed 
turned.     Since  there  has  been  a  more   careful  study  of   the   differences  in 
bones,  the  impossibility  of  diagnosing  from  a  process  the  direction  of  whose 
surface  is  determined  by  muscle  pull  is  readily  understood.     The  cervical 
spinous  processes  vary  in  individuals  of  the  same  family. 

3.  The  patient  should  always  be  asked  to  hold  his  head  easily  erect  when 
cervical  palpation  is  attempted. 


116  OSTEOPATHIC  MECHANICS 

test  for  motion  should  be  made  by  asking  the  patient  to  turn  the 
head  to  the  left,  whereupon,  if  the  third  were  not  in  lesion  but 
characterized  by  an  anomalous  large  anterior  tubercle,  movement 
would  be  felt.  If  however  the  third  is  in  lesion,  there  will  lie  no 
change  in  the  relations  of  the  third  and  fourth.  The  second  will 
advance  to  the  line  of  the  third,  perhaps,  but  of  the  line  of  anterior 
tubercles  below  the  second  the  third  will  be  noticeably  anterior. 
B's  head  should  then  be  turned  to  the  front,  whereupon  the 
anterior  tubercles  of  the  two  sides  will  be  found  equal  save  for  t  lie 
anterior  third.  B  is  asked  to  turn  his  head  to  the  right.  If 
movement  is  felt  between  the  third  and  fourth  tubercles,  the  third 
is  not  in  lesion,  but  if  the  prominence  of  the  third  is  in  no  way 
lessened  by  the  movement  of  right  rotation,  a  right  anterior  lesion 
is  present. 

EXPERIMENTAL  PALPATION,  H. — For  the  detection  of  the 
influence  of  sidebending  upon  the  lesioned  articulation,  experiment 
VII,  page  28,  should  be  repeated,  and  after  the  plan  of  experi- 
mental palpation,  G,  above,  a  determination  of  the  presence  of  a 
lesion  in  a  patient  supposed  to  have  an  anterior  fifth  cervical  on 
the  right  may  be  easily  made. 

Osteopathists  differ  in  the  manner  of  palpating  these  lesions. 
It  is  possible  to  detect  them,  after  some  experience,  by  palpating 
the  margins  of  articular  facets  posteriorly;1  by  palpating  the 


IX 


.  FIG.  44. — Drawing  to  represent  the  posterior  view,  of  a  right  anterior  fifth  cervical  lesion. 


1.  Method  preferred  by  Dr.  H.  H.  Fryette  of  Chicago. 


OSTEOPATHIC  MECHANICS  117 

lateral  surfaces  of  the  transverse  processes,  or  by  palpating 
medially  to  the  anterior  tubeicles.1  It  requires  experience  to 
determine  readily  which  vertebra  is  in  lesion.  The  axis  lacks 
tubercles  upon  its  transverse  processes  but  these  processes  after 
much  palpation  may  be  quite  readily  found.  The  sixth  cervical 
commonly  has  exceedingly  large  tubercles,  called  from  the  fact 
that  the  carotid  artery  may  be  easily  compressed  against  them, 
the  carotid  tubercles.  By  counting  upward  from  these  the  num- 
ber of  the  vertebra  in  lesion  may  be  determined. 

Lesions  of  the  epistropheus  may  be  difficult  to  diagnose  for 
the  reason  that  often  a  mass  of  muscle  or  connective  tissue  so 
surrounds  its  transverse  processes  that  palpation  reeds  to  be 
skilled  to  find  the  surfaces  of  the  transverse  processes  and  to 
determine  whether  or  not  they  are  in  lesion. 

Differential  diagnosis,  when  the  presence  of  an  anomalous 
vertebra  is  suspected,  may  be  made  by  restriction  of  motion,  the 
constant  sign  of  lesion.  The  cervical  area  is  subject  to  caries 
and  arthritis  and  the  student  should  exercise  care  in  differentiating 
these  cases2  by  the  history  of  the  case,  the  presence  of  deformity, 
and  of  characteristic  symptoms.3  Cervical  lesions  are  often 
difficult  of  diagnosis  and  obstinate  of  correction  due  to  the  fact 
that  there  has  been  calcareous  deposit  about  the  articular  processes. 

Of  the  causes  producing  cervical  lesions  the  commonest  are 
traumatism  and  infection.  The  usual  traumatisms  are  forcible 
twisting  or  sidebending  of  the  neck.  Of  the  infections  causing  a 
secondary  inflammation  of  the  cervical  articulations,  the  usual 
ones  are  tonsillitis,  influenza,  diphtheria,  scarlet  fever,  measles, 
mumps,  otitis  media,  mastoiditis,  and  acute  articular  rheumatism. 
Any  distrubance  in  the  blood  or  nerve  supply  to  the  articulation 
weakens  its  resistance  to  active  agents.  Sudden  muscular  con- 
tractions may  cuase  a  strain  of  a  cervical  joint  and  direct  violence 
may  also  produce  lesion.  Acute  wryneck  is  usually  followed  by 


1.  Method  preferred  by  Dr.  H.  W.  Forbes  of  Los  Angeles. 

2.  Dr.  C.  P.  McConnell  has  said  recently  that  diagnostic  ability  depends 
upon  differentiation  of  cause  from  effect.     This  is  particularly  true  when  one 
wishes  to  determine  the  difference  in  a  cervical  condition,  which  might  be  con- 
fused as  to  whether  arthritis  or  simple  chronic  rotation  lesion  with  deposit. 

3.  "Orthopedic  Surgery,"  Royal  Whitman,  1910,  pg.  46,  129,  131,  133. 
"Diseases  of  Infancy  and  Childhood,"  L.  E.  Holt,  M.  D.,  1906  edit,,  page  903. 


118  OSTEOPATHIC  MECHANICS 

one  or  more  cervical  subluxations.  Faulty  posture  from  ocular 
defect,  sleeping  with  the  head  sidebent  or  twisted,  occupations 
requiring  a  constant  turning  of  the  head,  are  all  predisposing 
factors  in  cervical  lesion  production. 

CORRECTIVE  MOVEMENTS 

THE  PRINCIPLES  OF  CORRECTION  FOR  CERVICAL  LESIONS  ARE 
ROTATION  AND  SIDEBENDING. 

GENERAL  RULES. — SINCE  ROTATION  AND  SIDEBENDING  ARE 
CONCOMITANT  A  CERVICAL  LESION  MAY  BE  CORRECTED  BY  PLACING 
THE  PATIENT  IN  THE  POSITION  OF  SIDEBENDING  AND  USING  THE 
MOVEMENT  OF  ROTATION  FOR  CORRECTION,  OR  BY  PLACING  THE 
PATIENT  IN  THE  POSITION  OF  ROTATION  AND  USING  THE  MOVE- 
MENT OF  SIDEBENDING  FOR  CORRECTION.1 

THE  ARTICULATING  SURFACES  MUST  RETRACE  THE  PATH  THEY 
TOOK  IN  THEIR  DISPLACEMENT.2 

There  is  no  area  of  the  spine  where  preliminary  treatment  is 
so  necessary  as  in  the  cervical  region.  The  muscles  are  many, 
their  fasciculi  take  origin  from  more  than  one  vertebra  usually, 
and  contractions  are  easily  induced  by  irritation  to  the  supplying 
nerve.  Patients  do  not  relax  easily  to  corrective  movements  and 
many  suffer  from  muscular  rigidities  incident  to  the  chronic  con- 
dition of  the  case.3 

A  certain  amount  of  massage  may  be  helpful  in  relaxation  of 
contracted  muscles  but  the  preferred  method  is  a  stretching  of  the 
tissues  by  putting  the  neck  through  the  normal  movements  of  the 
cervical  area,  flexion,  extension,  rotation,  and  sidebending.  The 
osteopathist  should  have  in  mind  separation  of  the  origin  and 
insertion  of  each  muscle.  In  this  way  a  direct  longitudinal  pull 
is  given  to  the  muscle  which  tends  to  overcome  its  contraction. 
The  separation  must  be  effected  slowly,  for  all  hurried,  jerky  move- 
ments defeat  their  own  purpose,  relaxation.  Nowhere  in  the  appli- 
cation of  osteopathic  mechanics  is  quiet  action,  carefulness  in  the 

1.  Whether  sidebending  or  rotation  be  initiative,  the  body  rotates  to  the 
concavity  of  the  curve  in  the  general  movement  preceding  lesion  production. 

2.  This  is  a  general  law  and  applicable  in  the  correction  of  all  joint  lesions. 

3.  Unquestionably  relaxation  makes  the  patient  ready  and  secondarily 
so  prepares  the  tissues  that  subsequent  movements  do  not  serve  to  lessen  his 
confidence. 


OSTEOPATHIC  MECHANICS  119 

application  of  force,  and  skill  more  necessary.  The  head  may  be 
taken  in  the  hands,  one  on  each  side,  one  below  the  occiput  and 
the  other  over  the  forehead,  or  with  one  below  the  occiput  and  the 
other  grasping  the  chin,  with  the  object  of  stretching  the  cervical 
region  by  pulling  the  head  in  the  direction  of  the  movement 
desired.  The  head  may  be  supported  by  one  hand  to  move  it  in 
a  desired  direction  while  the  other  hand  about  the  neck  assists. 
The  patient  may  be  seated  upon  a  stool  or  lying  supine  upon  a 
table  for  preliminary  treatment. 

When  the  patient  has  acquired  the  ability  to  relax  to  the 
general  movements  of  the  area,  he  should  then  be  given  the 
corrective  movement  by  degrees  until  he  relaxes  completely  so 
that  adjustment  shall  be  absolutely  painless  and  inoffensive. 
Such  preparatory  measures  may  require  several  visits;  they  may 
be  accomplished  at  the  first  treatment.  There  is  great  dissimilar- 
ity among  patients  in  this  respect. 

I.  FORBES'  1  MOVEMENT. — Let  B  be  assumed  to  have  a  right 
anterior  lesion  of  the  axis.  He  is  asked  to  sit  upon  a  stool  not  more 
than  sixteen  inches  high.  O  stands  behind  B  and  slightly  to  his 
left.  B  is  asked  to  lean  back  against  O  who  takes  hold  of  B's 
head  with  his  right  hand  and  lays  in  on  his  left  forearm,  his  palm 
against  B's  left  cheek,  the  fingers  of  his  hand  grasping  B's  chin, 
his  upper  arm  resting  against  the  top  of  B's  head.  O  places  his 
right  hand  against  the  right  side  of  B's  neck,  the  metacarpo- 
phalangeal  joint  of  the  index  finger  against  the  right  lamina  of  the 
third  cervical  vertebra  to  make  of  it  a  fixed  point.  The  web 
between  the  index  finger  and  the  thumb  rests  against  the  right 
side  of  B's  neck,  the  fingers  of  O's  hand  point  directly  forward  so 
that  they  do  not  touch  the  neck  and  induce  any  reflex  contractions 
by  the  contact.  The  palm  of  O's  right  hand  may  be  lifted  from 
the  side  of  B's  neck  or  applied  to  it,  as  the  habit  of  the  practician  is. 

Maintaining  this  position,  O  bends  B's  head  directly  over  his 
left  shoulder.  He  then  carries  his  head  forward  without  turning 
B's  face  to  right  or  left.  Then  pushing  against  the  angle  of  the 
mandible,  he  lifts  B's  chin  to  the  right  a  distance  of  about  an  inch. 
The  purpose  of  these  positions  may  be  explained,  thus :  sidebending 
to  the  left  exaggerates  the  lesion  slightly  and  helps  to  disengage 
the  surrounding  tissues.2  The  head  is  carried  forward  in  flexion 
to  straighten  the  cervical  curvature  that  later  rotation  may  be 

1.  I  have  chosen  to  name  this  movement  for  Dr.  H.  W.  Forbes  for  the 
reason  that  its  efficiency  well  deserves  the  appellation. 

2.  See  page  72,  line  13. 


120 


OSTEOHATHIC    MECHANICS 


FIG.  45. — Illustrating  the  first  half  of  the  Forbes'  movement  for  the  correction  of  a  right 
anterior  axis  lesion. 

accomplished  better  as  it  is  when  there  is  less  of  the  physiological 
curve  present;  flexion  also  localizes  rotation  to  the  uppermost 
area  of  the  cervical  region.  1  The  lifting  of  the  chin  is  for  the 
purpose  of  so  placing  the  planes  of  the  articular  surfaces  of  the 
axis-third  articulation  that  they  shall  not  be  jambed  by  any 
force  directed  against  them. 

Pressure  is  now  placed  upon  the  top  of  B's  head  to  hold  in 
close  apposition  the  facets  of  the  left  side  so  that  movement  among 
them  is  limited  in  extent  to  the  purposes  of  the  correction. 

B's  face  is  now  turned  upward  and  to  the  right,  through  an 
arc  measuring  about  an  inch,  and  then  back.  This  is  repeated 
several  times,  while  the  pressure  on  the  top  of  his  head  remains 
unchanged  and  the  fixed  point2  is  immovable.  When  perfect 

1.  See  page  26,  paragraph  3. 

2.  The  fixed  point  is  indispensable  to  the  adjustment  of  the  lesion.     With- 
out its  maintenance,  each  cervical;  articulation  may  be  twisted  and  its  arti- 
culating surfaces  separated  by  this  movement,  often  resulting  in  a  series  of 
popping  sounds. 


OSTEOPATHIC  MECHANICS  121 

relaxation  is  determined  by  the  patient's  devitalization  of  the  head, 
a  sudden  increase  of  the  turning  of  the  head,  to  a  distance  of  two 
or  three  inches,  is  made  at  the  same  time  a  slight  increase  is  felt  in 
the  pressure  exerted  by  the  right  hand  and  the  left  arm  or  axilla. 
This  rotation  should  accomplish  a  return  of  the  right  inferior 
articular  facet  of  the  second  cervical  to  a  position  of  apposition 
upon  the  corresponding  superior  facet  of  the  third,  which  adjusts 
the  lesion. 

Holding  the  head  in  the  position  attained  after  adjustment 
has  been  made,  and  losing  none  of  the  pressure  upon  the  head  or  at 
the  fixed  point,  the  head  is  brought  over  toward  the  right  shoulder 
in  right  sidebending.  Pressure  is  repeatedly  relaxed  and  increased 
upon  the  top  of  the  head  in  this  position  for  the  purpose  of  grinding 
any  calcareous  deposit  that  may  have  formed  and  also  for  a  stim- 
ulative effect  upon  the  elastic  fibres  of  the  right  capsular  ligament 
and  the  fasciculi  of  the  muscles  that  have  become  atonic.2 

A  slight  popping  sounds  usually  occurs  at  the  moment  preceding 
adjustment  and  is  probably  due  to  the  separation  of  the  parts  of 
the  articulating  surfaces  that  had  been  held  immobilized  in  lesion. 

Lesions  from  the  axis  to  the  fourth  are  corrected  as  the  axis 
lesion  in  the  above  movement,  the  head  in  each  lower  lesion  being 
bent  less  far  to  the  left  side,  and  the  fixed  point  being  changed 
always  to  the  lamina  of  the  vertebra  below  the  one  in  lesion.  The 
reverse  by  position  will  adjust  lesions  upon  the  left  side  of  the 
cervical  region. 

II.  APPHOXIMATING  MOVEMENT. — B  is  assumed  to  have  a 
right  anterior  lesion  of  the  third  cervical  vertebra.  B  is  asked  to 
lie  supine  upon  the  table.  0  draws  him  upward  until  his  head 
extends  just  beyond  the  edge  of  the  table  and  then  places  a  pillow 
against  the  top  of  his  head  and  holds  it  firmly  by  pressure  with 
abdomen  against  the  pillow.  Rising  slightly  on  his  tiptoes,  O 
flexes  B's  head  according  to  the  vertebra  that  is  in  lesion.  If  B 
has  a  right  anterior  axis,  O  flexes  B's  head  as  much  as  is  com- 
fortable. If  B  has  a  right  anterior  sixth  cervical,  O  flexes  B's 
head  merely  enough  to  raise  it  from  the  table.  Flexion  localizes 
rotation  in  the  cervical  area;  the  greater  the  degree  of  flexion,  the 
less  in  extent  the  number  of  vertebrae  taking  part  in  rotation,  from 


1.  This  also  stretches  the  contractured  muscles  on  the  opposite  side  of 
the  neck.     Any  localized  right  sidebending  or  rotation  will  stretch  them. 

2.  It  is  usually  best  to  explain  in  advance  to  the  patient  that  a  popping 
sound  may  be  heard  for  many  people  have  erroneous  ideas  concerning  joint 
sounds.     The  movement  should  be  absolutely  painless  to  the  patient.     The 
amount  of  force  necessary  for  the  adjustment  is  slight.     The  frequent  fault 
with  beginners  is  using  too  much  force. 


122  OSTEOPATHIC  MECHANICS 

the  axis  downward.  In  this  movement  B  is  assumed  to  have  a 
right  anterior  axis  lesion. 

O  places  both  hands  underneath  B's  neck,  the  right  hand  to 
make  a  fixed  point  of  the  third  cervical  vertebra,  by  pressure 
against  the  spinous  process  and  the  right  lamina  or  transverse 
process.  O's  left  hand  holds  the  head  under  the  occiput  with  the 
heel  of  the  hand  against  the  parietal  or  the  temporal  bone  to  guide 
the  head  in  movement. 

O  sidebends  B's  head  to  the  right  and  rotates  it  slightly  to 
the  same  side,  at  the  same  time  maintaining  a  steady  but  not 
painful  pressure  against  the  top  of  his  head.  The  movement  is 
directed  toward  returning  the  right  inferior  facet  of  the  axis  back- 
ward and  downward  upon  the  right  superior  facet  of  the  third 
vertebra.  Slight  relaxation  of  the  pressure  is  made  as  the  head  is 
returned  to  the  median  line  but  increased  again  upon  repel  it  ion 
of  the  movement.  When  relaxation  has  been  secured,  by  an 
increase  of  sidebending  and  rotation  and  with  no  loss  of  pressure 
upon  the  head,  adjustment  is  usually  effected.1 

This  movement  is  exceedingly  gentle  and  to  patients  who  are 
high-strung  or  nervous  it  is  well  adapted.  It  may  be  used  in  the 
correction  of  any  of  the  anterior  cervical  lesions. 

III.  UPRIGHT-ROTATION  MOVEMENT. — B  is  assumed  to  have 
a  right  anterior  fifth  cervical  lesion.  He  sits  upon  the  stool  as 
in  movement  I,  with  O  standing  behind  him  and  slightly  to  the 
left.  O  holds  B's  head  and  places  his  left  hand  against  the  lamina 
of  the  sixth  as  in  the  above  movement.  B's  head  is  bent  slightly 
to  the  left.  O  then  rotates  B's  head  directly  to  the  right  in  an  arc 
of  about  thirty  degrees,  at  the  same  time  maintaining  firmly  the 
fixed  point,  the  sixth  vertebra.  He  repeats  the  rotation  until 
relaxation  is  secured  and  then  increases  the  arc  of  rotation  with  a 
quick  movement  which  should  correct  the  lesion.2  To  hold  the 
adjustment,  further  movement  is  necessary.  O  should  maintain 
the  rotation,  lift  slightly  upon  B's  chin,  hold  the  pressure  against 
the  top  of  his  head  and  sidebend  his  head  to  the  right  at  the  same 
time  thrusting  the  sixth  cervical  vertebra  to  the  left  and  slightly 
downward  by  increasing  the  pressure  against  the  lamina  of  that 
vertebra.  This  movement  of  sidebending  should  be  repeated  by 
bringing  B's  head  back  to  the  erect  position,  not  losing  the  rota- 
tion and  the  pressures  and  again  sidebending  it. 

This  movement  is  corrective  for  anterior  cervical  lesions  of 
the  fifth  and  sixth  cervical  vertebrae.  Movements  I  and  III  may 


1.  A  reversing  of  hands  and  movements  will  correct  lesions  upon  the  left. 

2.  Illustrated  by  figure  46. 


OSTEOPATHIC  MECHANICS 


123 


FIG.  46. — Illustrating  the  position  in  the  upright-rotation  movement  when  the  right 
inferior  facet  of  the  fifth  is  brought  to  apposition  with  the  corresponding  superior  facet  of  the 
sixth. 

be  adapted  to  the  supine  position  by  changing  the  positions  of 
the  hand  and  arm  which  hold  the  head,  bending  slightly  over  the 
patient,  so  that  the  left  forearm  may  serve  to  assist  in  guiding  the 
head  in  the  movements  to  the  right. 

AFTER-TREATMENT 

The  articulations  of  the  cervical  area  require  a  very  consider- 
able amount  of  treatment  following  the  adjustment  of  lesions  to 
maintain  the  correction.  The  very  flexibility  of  the  cervical 
region,  a  necessity  in  the  carriage  of  the  head,  makes  that  area  a 
prey  to  faulty  habits  of  posture.  A  constant  problem  with  the 
human  being  is  holding  his  head  erect.  He  is  unconscious  of 
effort  in  that  direction  save  when  he  is  asked  to  change  a  habit. 


124  OSTEOPATHIC  MECHANICS 

He  finds  himself  the  slave  of  attitude  and  it  requires -vigilance  and 
perseverence  to  overcome  tendencies  to  certain  positions  and 
movements. 

Following  adjustment  the  articulation  should  be  put  passively 
through  the  normal  movements  and  the  active,  resistance  move- 
ments should  be  made  with  the  physician  offering  the  resistance. 
These  movements  should  be  rotation  and  sidebending  to  the  side 
of  the  lesion  to  stimulate  to  activity  the  muscle  fasciculi  stretched 
and  atrophied  from  disuse,  to  stretch  the  antagonistic  muscles 
of  the  opposite  side  which  have  become  contracted  and  shortened. 

There  is  a  condition  in  the  cervical  area  which  has  been 
termed  the  "wrecked  neck"  which  may  be  described  as  a  condi- 
tion of  relaxed  articulations.  It  is  unquestionably  due  to  improper 
treatment  that  such  relaxations  are  found,  although  in  a  case  of 
general  debility  one  might  expect  to  find  ligamentous  tissues  and 
joints  unstable.  The  rough  handling  of  the  imitators  of  oste- 
opathy will  produce  strains  of  the  spinal  articulations;  careless 
snapping1  of  cervical  joints  will  cause  looseness  in  capsules  and 
limiting  tissues.  Especially  is  this  true  when  the  limitations  of 
extension  or  backward  movement  of  the  superior  articular  facets 
are  little  understood.  The  treatment  of  such  a  neck  should  begin 
with  resistance  movements  in  flexion  and  extension,  for  nearly 
all  of  the  flexors  and  extensors  are  likewise  rotators  and  lateral 
flexors.  Rarely  should  adjustment  be  made  until  the  tissues  of 
the  neck  are  strong  enough  to  hold  correction. 

Cervical  lesions2  may  be  corrected  in  one  treatment  in  a  neck 
that  is  otherwise  strong.  Without  the  proper  amount  of  after- 
treatment  these  lesions  may  recur  constantly  and  both  physician 
and  patient  think  that  they  are  difficult  of  adjustment.  Fifteen 
treatments  should  overcome  any  cervical  lesion  that  is  not  fixed 
by  deposit. 


1.  The  habit  of  putting  a  cervical  joint  upon  tension  and  then  "popping" 
it  is  one  to  be  condemned  in  no  uncertain  language.     Students  who  are  mere 
beginners  in  osteopathic  colleges  easily  acquire  by  observation  the  ability  to 
"crack"  a  neck  and  untold  detriment  often  results.     Patients  who  have  had 
adjustments  affording  instant  relief,  often  twist  their  necks  and  jerk  them 
about  until  joints  "give"  with  the  suggestive  effect  of  removal  of  the  irritative 
cause.     Cervical  treatment  should  be  mastered  by  slow  processes. 

2.  A  comprehensive  article  upon  the  subject  appeared  in  the  Journal  of 
the  A.  O.  A.,  May,  1909,  page  385,  from  the  pen  of  Dr.  H.  W.  Forbes. 


OSTEOPATHIC  MECHANICS  125 

COUNTERBALANCING  LESIONS 

When  a  cervical  lesion  is  present,  there  may  be  detected  a 
lengthening  of  the  side  of  the  neck  upon  which  the  lesion  is  found, 
by  reason  of  the  immobilization  of  the  inferior  facet  in  a  position 
forward  and  upward  upon  the  superior  facet  below.  In  conse- 
quence of  this  lesion,  the  crown  of  the  head  will  be  tilted  and  turned 
slightly  toward  the  side  opposite  the  lesion.  To  overcome  this 
attitude  it  will  be  necessary  to  increase  the  height  of  the  other 
side  of  the  neck  by  a  secondary  cervical  lesion  below  or  by  a  turn- 
ing or  lateral  bending  of  the  head  toward  the  side  of  the  primary 
lesion. 

A  cervical  lesion  may  itself  be  secondary  to  an  occipital  lesion 
above  and  in  such  a  case  the  indicated  treatment  is  first  adjust- 
ment of  the  primary  lesion,  followed  by  correction  of  the  secondary 
lesion,  should  it  persist,  and  close  attention  to  resistance  exercises. 
Cervical  curvatures,1  in  a  large  percentage  of  cases,  are  compensa- 
tory in  character,  the  primary  cause  being  an  occipital  or  atloid 
lesion.  Habit2  is  a  predisposing  factor  of  great  importance  in 
these  patients. 

1.  See  page  47,  line  5. 

2.  The  interesting  case  of  Mr.  C.  E.  Moyer  of  the  June,  1916,  Class,  may 
be  cited  in  this  connection.     Mr.  Moyer  has  been  a  professional  baseball 
pitcher.     At  the  close  of  each  season,  his  cervical  area  has  presented  lesions 
which  could  be  explained  by  reason  of  his  position  on  the  diamond     He  has 
had  a  slight  cervical  curvature,  convex  to  the  right,  made  necessary  by  almost 
constantly  watching  the  first  base;    in  addition  he  has  had  a  rotation  of  the 
occiput  and  atlas  to  the  right,  the  result  of  turning  to  throw  the  ball.     The 
struggle  for  supremacy  among  the  muscles  of  the  neck  has  brought  among 
them  an  unusual  division  in  action. 

Bibliography:  Cunningham,  ibid.,  pg.  90-93,  305-309,  368,  392,  438- 
446,  467-470. 

Deaver,  ibid.,  I,  pg.  372,  377,  400-407.,  412-424. 

Frazer,  ibid.,  pg.  15-24. 

Gray,  ibid.,  pg.  49-53,  268-273. 

Morris,  ibid.,  pg.  31-35,  224-232,  320,  321,  353,  356,  414-419,  502. 

Scudder's  "Treatment  of  Fractures,"  1914,  pg.  644-651. 


126  OSTEOPATHIC  MECHANICS 


CHAPTER  VII 
SACRO-ILIAC  LESIONS 

One  of  the  earliest  discoveries  of  the  founder  of  the  science  of 
osteopathy  was  that  the  sacro-iliac  joint  is  a  freely  movable  articu- 
lation and  therefore  subject  to  subluxation.  This  joint  had  been 
termed  by  anatomists  immovable  but  later,  when  Sir  Richard 
Quain,  the  great  English  surgeon,  called  attention  to  the  manner 
in  which  the  sacrum  was  suspended  between  the  ossa  coxae,  the 
sacro-iliac  articulation  was  decided  to  be  slightly  movable  and 
was  classified  among  the  amphiarthrodia.  About  twenty  years 
after  Dr.  A.  T.  Still  had  been  adjusting  subluxations  of  the  innom- 
inates  and  fully  ten  years  after  he  had  taught  the  osteopathic 
methods  of  reduction  for  these  subluxations,  followers  of  the 
regular  school  of  medicine  began  research  into  the  action  of  this 
joint,  with  the  noticeable  result  that  there  is  scarcely  a  medical 
text  in  gynecology,  obstetrics,  or  orthopedic  surgery  today  but 
which  speaks  of  strain  of  these  articulations;  the  methods  therein 
offered  for  their  correction  are  chiefly  through  rest,  mechanical 
supports,  and  the  use  of  weights. 

Not  only  can  the  researches  of  the  osteopathic  scientists  now 
offer  a  more  thorough  knowledge  of  the  sacro-iliac  articulation 
but  they  can  give  reasons  for  differences  in  pelvic  inclination, 
offer  etiologic  causes  for  pelvic  congestion,  and  explain  the  founda- 
tion for  the  faulty  attitudes  of  the  straight  spine,  flat  chest,  and 
round  shoulders. 


Bibliography:     Marion  E.  Clark,  ibid.,  pg.  301-330. 

Cunningham,  ibid.,  pg.  98-99,  228-238,  334-339,  301. 

Dunlop,  "Amer.  Jour.  Ortho.  Surg.",  July  1907,  pg.  151. 

H.  W.  Forbes,  "Jour,  of  A.  O.  A.",  Aug.  1909,  Apr.  and  May,  1910. 

Ernest  Frazer,  ibid.,  pg.  37-43,  115-134. 

Goldthwait  and  Osgood,  "Bos.  Med.  and  Sur.  Jour.",  Mav  25  and  June 
1,  1905. 

Gray,  ibid.,  pg.  58-62,  207-220,  289-295. 

Lovett,  ibid.,  pg.  5-6. 

C.  P.  McConnell,  in  "Jour,  of  A.  O.  A.",  Nov.  and  Dec.,  1912. 

McConnell  and  Teall,  ibid.,  pg.  57-60,  87-90. 

Morris,  ibid.,  pg.  39-42,  169-177,  232-240. 

Tasker,  "Principles  of  Osteopathy",  1913  edit.,  pg.  269-282;  461-470. 

Royal  Whitman,  ibid.,  pg.  146-148. 


OSTEOPATHIC  MECHANICS  127 

The  pelvis  is  formed  by  the  union  of  four  bones,  the  sacrum, 
the  two  innominates  or  hip-bones,  and  the  coccyx.  It  has  four 
joints  in  adult  life,  the  two  sacro-iliac  articulations,  the  symphysis 
pubis,  and  the  sacrococcygeal.  It  is  divided  into  two  parts  at 
the  junction  of  the  planes,1  the  promontory  of  the  sacrum,  and  the 
upper  margin  of  the  pubes.  The  larger  and  upper  cavity  is  called 
1  he  false  pelvis,  the  lower  and  smaller,  the  true  pelvis.  The  upper 
opening  of  the  true  pelvis  is  termed  the  inlet,  the  lower  opening 
the  outlet.  The  pelvis  is  spoken  of  as  a  bony  girdle  or  basin  which 
to  the  unthinking  mind  might  convey  the  idea  of  solidity  with 
joints  subject  to  little  change.  On  the  contrary,  the  two  greater 
joints  of  the  pelvis,  the  sacro-iliac,  are  now  classed  among  the 
diarthrodia,  freely  moving  articulations. 

The  sacrum  is  wedge-shaped  from  above  downward,  its  base 
articulating  with  the  fifth  lumbar  vertebra;  it  is  also  wedge-shaped 
from  before  backward,  a  fact  that  makes  cle,ar  the  statement 
that  the  sacrum  is  held  suspended  between  the  innominates  by 
strong  ligaments  instead  of  completing  the  bony  girdle  as  the 
keystone  caps  the  arch. 

The  ligaments  of  the  sacro-iliac  joint  are  the  anterior  sacro- 
iliac,  the  posterior  sacro-iliac,  and  the  interosseous  sacro-iliac, 
the  last-named  the  most  important  ligament  of  the  articulation. 
It  consists  of  very  strong  fibres  of  uneven  length  passing  from  the 
rough  area  on  the  ilium  posterior  and  adjacent  to  the  auricular 
surface,  medially  and  downward,  to  be  attached  to  the  posterior 
surface  of  the  upper  two  segments  of  the  sacrum.  The  ligaments 
of  the  articulation  are  in  effect  capsular  ligaments  with  specially 
developed  bands  of  strength,  holding  the  surfaces  opposed  so  that 
dislocation  may  be  prevented  yet  free  movement  permitted. 

The  sacrum  and  ischium  are  connected  by  two  ligaments  of 
great  strength  which  limit  the  motion  of  the  joint,  the  sacro-tuber- 
ous  and  sacro-spinous,2  both  of  which  are  attached  to  the  posterior 
aspect  and  lateral  margins  of  the  sacrum  and  coccyx,  and  the 
first  has  also  an  attachment  to  the  posterior  inferior  spine  of  the 
ilium.  The  sacro-tuberous  ligament  is  inserted  into  the  medial 


1 .  The  iliopectineal  lines. 

2.  Old  terminology,  greater  and  lesser  sacro-sciatic  ligaments. 


128  OSTEOHATHIC    MECHANICS 

border  of  the  tuberosity  of  the  ischium;  the  sacro-spinous  into  t  he 
inner  surface  and  borders  of  the  spine  of  the  same  boric. 

The  pubic  articulation  is  an  amphiarthrosis,  has  slight  mobil- 
ity, and  is  influenced  by  lesions  of  the  sacro-iliac  joints. 

EXPERIMENTAL  PALPATION,  I. — Ask  the  subject  to  lie  upon 
the  table  upon  his  face,  with  his  hands  resting  palm  downward 
upon  the  table  beside  his  shoulders.  Ask  him  to  raise  his  ioi>o 
gradually  backward  from  the  table  until  only  the  lower  part  of 
the  abdomen  rests  upon  the  table.  He  must  be  instructed  to  raise 
his  body  by  the  power  on  the  muscles  of  his  arms,  so  that  the 
extensor  muscles  of  the  back  shall  remain  relaxed.  O  places  his 
thumbs  upon  the  coccygeal  end  of  the  sacrum,  his  index  fingers 
upon  the  base  of  the  sacrum  close  to  the  over-lapping  surface  of 
the  ilium,  the  middle  fingers  upon  the  posterior  superior  spines  of 
the  innominates.  While  B  rests  upon  the  table,  O  palpates  very 
carefully  the  relations  of  the  surfaces  his  thumb  and  fingers  rest 
upon,  as  to  planes,  distances  apart,  etc.  When  B  reaches  the 
amount  of  extension  asked,  O  should  note  that  the  coccygeal  end 
of  the  sacrum  is  below  the  horizontal  level  of  the  first  position; 
that  the  index  fingers  are  more  nearly  at  a  level  with  the  middle 
fingers,  and  that  there  is  a  slight  increase  of  distance  between  the 
middle  fingers.  B  is  asked  to  return  to  the  prone  position.  Just 
before  his  body  rests  against  the  table  O  should  be  able  to  note  the 
motion  that  takes  place  in  the  sacro-iliac  articulations.  There 
must  be  no  mistaking  of  the  contraction  of  the  erector  spinae  mus- 
cles for  actual  movement  in  these  articulations  and  for  this  reason 
B  must  be  trained  to  keep  his  extensor  muscles  relaxed  while  he 
raises  his  body  by  the  muscular  strength  of  his  arms. 

EXPERIMENTAL  PALPATION,  J. — Ask  the  subject,  B,  to  sit 
upon  the  end  of  the  table,  O  sitting  upon  a  stool  behind  him.  An 
assistant,1  C,  may  stand  in  front  of  B,  his  hands  under  B's  axillae 
to  support  him.  O  places  his  thumbs  and  fingers  as  in  the  above 
experiment.  O  bends  his  head  forward  to  support  the  weight 
of  B's  trunk  when  B  moves  backward  in  extension,  unless  C  is 
able  to  hold  B's  weight.  B  is  asked  to  bend  forward  in  much 
flexion.  O  should  now  observe  that  the  coccygeal  end  of  the  sa- 
crum has  become  prominent  posteriorly,  that  the  levels  of  the 
index  and  middle  fingers  differ  markedly,  that  the  middle  fingers 
are  less  far  apart  than  in  the  prone  position  in  the  last  experiment. 
B  is  asked  to  carry  his  torso  back  in  extension,  or  C  is  instructed 
to  support  B  as  B  leans  backward.  B's  upper  thoracic  area  comes 

'  1.  An  assistant  is  required  when  a  flexible  subject  is  not  easily  obtained. 
Any  person  who  understands  how  to  relax  and  who  is  not  obese  will  be  a  suit- 
able subject  for  experimental  palpation. 


129 


FIG.  47. — Illustrating  a  manner  of  palpating  for  motion  in  the  sacro-iliac  articulations. 
The  palmar  surfaces  of  the  thumbs  rest  across  the  adjacent  surfaces  of  the  posterior  superior 
iliac  spines  and  the  posterior  surface  of  the  sacrum. 

to  the  level  of  O's  head  and  he  rests  against  O's  head.  O  should 
observe  that  the  relative  condition  of  the  palpated  surfaces  change 
with  the  movement.  The  coccygeal  end  of  the  sacrum  moves 
forward,  the  middle  fingers  separate,  the  index  fingers  approach 
the  level  of  the  middle  fingers,  thus  proving  that  the  axis  of  motion 
for  the  sacro-iliac  joints  is  a  line  which  passes  through  each  articu- 
lar surface  at  its  central  point  and  through  the  second  sacral 
segment. 

EXPERIMENTAL  PALPATION,  K. — Ask  the  subject,  B,  to  stand 
upon  the  floor  with  his  feet  several  inches  apart.  O  sits  behind 
him  upon  a  high  stool  and  places  his  thumbs  against  the  margins 
of  the  ilia,  the  tips  of  his  thumbs  resting  upon  the  posterior,  ad- 
jacent surface  of  B's  sacrum.  B  is  then  asked  to  bend  forward 
from  the  waist.  0  should  observe  that  the  tips  of  his  thumbs 
move  slightly  forward  in  relation  to  the  first  joint  of  his  thumbs 


130 


OSTEOPATHIC  MECHANICS 


P.S.'b. 


Fio.  48. — Cross  section  through  the  second  sacral  segment  of  the  pelvis,  as  seen  from  above, 
showing  the  inlet,  outlet,  articulations,  and  ligaments.  P.  S.  S.,  the  posterior  superior  spine 
of  the  ilium.  I,  The  interosseous  and  posterior  sacro-iliac  ligament.  S.  S.,  sacro-sciatic  liga- 
ments, great  and  lesser. 

which  rest  against  the  ilia  and  also  that  the  distance  between  the 
ilia  is  lessened.  B  is  asked  to  resume  the  erect  position  and  bend 
backward  from  the  waist  in  extension.  It  may  now  be  noted  that 
the  tips  of  the  thumbs  move  backward  until  they  are  nearly  in 
the  same  vertical  plane  as  the  first  joints. 

These  movements  should  be  repeated  until  O  has  demonstrat- 
ed for  himself  the  character  and  amount  of  the  motion  in  B's 
sacro-iliac  articulations. 

A  consideration  of  each  movement  in  detail  is  important. 
When  the  base  of  the  sacrum  moves  forward  in  flexion,  the  move- 
ment is  limited  by  the  sacro-sciatic  ligaments  which  being  attached 
below  to  the  end  of  the  sacrum  and  the  coccyx,  are  stretched  taut 
when  those  bones  move  upward  and  backward.  If  palpation  is 
made  through  the  rectum,  the  tautness  of  these  ligaments  is  easily 
demonstrated.  They  may  be  called  the  check-ropes  of  the  sacro- 
iliac  articulations. 


OSTEOPATHIC  MECHANICS 


131 


If  with  a  steel  tape1  measurement  has  been  made  of  the  distance 
between  the  two  posterior  superior  spines  of  the  ilia,  a  second  meas- 
urement made  after  flexion  will  show  exactly  that  the  posterior 
superior  spines  are  closer  together  than  in  the  upright  position  of 
the  normal  pelvis.  If  a  fixed  point  on  the  posterior  surface  of 
the  sacrum  be  chosen,  as  for  example  the  second  sacral  spinous 
process,  and  measurements  made  from  it  to  each  posterior  superior 
iliac  spine  in  each  of  these  positions,  the  same  observation  may  be 
made,  namely,  that  the  superior  spines  move  toward  each  other 
slightly  in  flexion  of  the  sacrum. 

With  a  pelvic  model  having  movable  articulations,  when 
flexion  of  the  sacrum  is  produced,  there  are  noticeable  changes  in 
the  pelvic  outlet  and  inlet:  the  tuberosities  of  the  ischii  move 
outward;  the  outlet  is  widened  laterally  and  antero-posteriorly; 
the  anterior  superior  spines  of  the  ilia  are  less  widely  separated, 
thus  reducing  the  broad  diameter  of  the  false  pelvis;  the  lumbo- 


FIG.  49. — Cross  section  through  the  second  sacral  segment  showing  the  change  in  the 
diameters  of  the  outlet  of  the  pelvis  when  a  flexion  lesion  of  the  sacrum  is  present. 

1.  A  narrow  steel  tape  is  best  for  there  is  little  chance  of  its  being  injured 
by  use.  A  cotton  or  linen  tape  may  be  stretched  so  that  its  measurement  is 
quite  inaccurate.  A  tape  having  the  metric  system  upon  one  side  and  the 
English  upon  the  other  is  to  be  preferred. 


132  OSTEOPATHIC  MECHANICS 

sacral  angle  projects  forward  into  the  false  pelvis,  and  the  antero- 
posterior  diameter  of  the  inlet  is  narrowed. 

Passing  in  review  all  these  facts,  it  is  possible  to  grasp  what 
the  motion  between  the  articular  surfaces  of  the  sacrum  and  ilia 
is.  Rotation  is  proved  by  the  upward  movement  of  the  inferior 
extremity  of  the  sacrum  and  by  the  forward  movement  of  the  base 
of  the  sacrum  occurring  at  one  and  the  same  time.  Gliding,  which 
is  concomitant  with  rotation,  is  proved  by  the  separation  of  the 
ischial  tuberosities  and  by  the  narrowing  of  the  distance  bet  ween 
the  anterior  superior  spines.  Upon  the  strength  of  the  posterior 
sacro-iliac  Ligaments  depends  the  prevention  of  anterior  dislocation 
in  this  position,  which  the  weight  transmitted  from  the  body  above 
through  the  base  of  the  sacrum  tends  to  produce. 

FLEXION  LESION   OF  THE  SACRUM 

Immobilization,  partial  or  complete,  may  take  place  in  the 
pelvis  in  flexion  of  the  sacrum.1  Such  a  lesion  is  spoken  of  as  a 
flexion  lesion  of  the  sacrum  or  as  bilaterally  posterior  innominate 
lesions.  Its  usual  cause  is  debility,  weakness  of  the  flexor  muscles, 
undue  contraction  of  the  extensors  from  irritation,  faulty  habits 
of  posture,  improper  clothing,  and  rachitis.  It  is  most  frequently 
found  in  children  and  is  accompanied  by  round  shoulders  and 
sunken  chest.2  The  lumbar  area  m&y  or  may  not  go  forward  in 
lordosis3  and  the  abdomen  usually  protrudes. 

When  a  flexion  lesion  of  the  sacrum  is  thought  to  be  present 
from  the  appearance  of  the  patient  as  above  described,  the  diag- 
nosis may  be  established  by  the  following  signs : 

1.  Limited  motion  in  the  sacro-iliac  articulations. 

2.  Decreased  distance  between  the  posterior  superior  spines 
when  compared  with  the  average  which  is  three  and  one-half 
inches. 

3.  Taut  sacro-sciatic  ligaments. 

4.  The  presence  of  counterbalancing  lesions,  most  commonly 
a  lumbar  lordosis. 


1.  This  lesion  has  been  termed  the  anterior  sacrum. 

2.  Cf.  Loyett.  ibid.,  Chap.  XIII,  page  178-180,  182. 

3.  Lordosis  is  the  term  for  an  increase  in  the  lumbar  curve,  convex  an- 
teriorly. 


OSTEOPATHIC  MECHANICS  133 

CORRECTIVE  MOVEMENTS 

THE  PRINCIPLES  OF  CORRECTION  FOR  A  FLEXION  LESION  OF 
THE  SACRUM  ARE  EXTENSION  OF  THE  SACRUM  OR  FLEXION  OF 
BOTH  INNOMINATES. 

Since  these  lesions  are  of  gradual  production,  correction  must 
proceed  slowly  with  attention  to  the  removal  of  the  cause  when 
that  lies  in  removable  conditions,  as  in  faulty  posture  or  unhygienic 
surroundings. 

Preliminary  treatment  is  of  much  advantage  in  these  cases 
for  the  muscles  of  the  lumbar  area  of  the  spine  and  the  thigh  are 
often  unduly  contracted  and  require  relaxation.  Any  unbalance 
of  the  pelvis  will  cause  marked  deviations  from  the  normal  in  the 
spine  above  or  in  the  muscles  which  hold  the  pelvis  upright.  The 
effects  of  unbalance,  wherever  found,  must  be  overcome  as  early 
in  the  treatment  of  the  case  as  possible. 

I.  EXTENSION-HOLDING  MOVEMENT. — Let  B,  who  is  assumed 
to  have  a  flexion  lesion  of  the  sacrum,  lie  prone  upon  the  table. 
O  standing  beside  the  table  places  his  hands  upon  the  posterior 
superior  spinous  processes  of  the  ilia  and  presses  firmly  against 
these  while  B  by  lifting  himself  with  his  arms  carries  his  trunk 
backward  in  extension.  When  B  has  reached  the  amount  of 
extension  desirable,  O  should  place  his  hands,  one  over  the  other, 
against  the  lower  part  of  the  sacrum,  below  the  segment  through 
which  passes  the  axis  of  rotation,  and  exert  firm  pressure  while  B 
returns  to  the  prone  position.  The  movements  B  executes  should 
be  performed  slowly. 

Any  of  the  corrective  movements  for  a  posterior  innominate 
lesion  may  be  used  in  the  correction  of  the  flexion  sacral  lesion  by 
giving  the  movement  as  though  for  lesions  of  both  innominates.1 

Material  assistance  may  be  had  from  the  patient  in  the  over- 
coming of  this  lesion  by  the  practice  of  extension  at  home  and 
also  by  taking  the  creeping  exercises,  before  recommended.2  As 
soon  as  the  sacro-iliac  articulations  have  normal  motion  and  the 
posture  has  markedly  improved,  the  patient  should  be  entered  in  a 
reputable  gymnasium  for  a  thorough  course  especially  directed  to 

1.  See  page  146. 

2.  See  page  41,  footnote  1.     The  patient  should  creep  directly  ahead 
instead  of  in  a  circle. 


134 


OSTEOPATHIC  MECHANICS 


the  development  of  the  muscular  system  and   respiratory  im- 
provement. 

SACRAL  EXTENSK  >X 

When  the  base  of  the  sacrum  moves  backward  in  extension, 
the  movement  is  limited  by  the  interposition  of  the  anterior  sur- 
face of  that  bone,  the  base  of  the  second  wedge  of  the  sacrum. 
Dislocation  is  therefore  an  impossibility  in  this  direction.  If 
the  distance  between  the  posterior  superior  spines  of  the  ilia  is 
measured  and  compared  with  the  same  distance  in  the  normal 
upright  position,  it  will  be  found  to  be  greater  in  extension,  there- 
fore it  is  proved  that  the  ilia  glide  outward  and  forward  when  the 
sacrum  rotates  backward;  simultaneously  the  ischii  will  glide  back- 
ward and  inward.  As  the  result  of  these  changes,  the  false  pelvis 
is  broadened  laterally,  the  distance  between  the  anterior  superior 
spines  is  greater,  the  inlet  of  the  true  pelvis  will  be  widened  in 
both  diameters,  the  outlet  of  the  pelvis  will  be  narrowed  corre- 
spondingly, and  the  sacro-sciatic  ligaments  will  be  relaxed. 


.  -p.  s.s. 


FIG.  50. — Cross  section  through  the  second  sacral  segment  of  the  sacrum,  when  an  ex- 
tension lesion  of  the  sacrum  is  present.  P.  S.  S.,  posterior  superior  spine.  I,  interosseous  and 
posterior  sacro-iliac  ligament.  S.  S.  sacro-sciatic  ligaments.  The  changed  diameter  of  the 
pelvic  outlet  is  shown. 


OSTEOPATHIC  MECHANICS  135 

EXTENSION   LESION   OF  THE  SACRUM 

Immobilization  of  the  sacro-iliac  joints  may  take  place  with 
the  sacrum  in  the  position  of  extension.  Its  causation  is  debility, 
infectious  diseases,  especially  pneumonia,  injuries  to  the  spine, 
the  slouched  position  in  sitting,  especially  when  sitting  is  accom- 
panied with  continuous  jarring  as  in  riding  in  conveyances  day 
after  day,1  weakness  of  the  extensor  muscles,  contraction  of  the 
flexors,  a  shifting  of  the  line  of  gravity  backward  from  its  wonted 
plane  in  front  of  the  sacro-iliac  joints  and  the  greater  part  of  the 
vertebral  bodies.  Tuberculosis  in  adults  with  the  secondary 
changes  that  take  place  in  posture  may  predispose  to  strain  of 
the  sacro-iliac  articulations. 

The  appearance  of  a  patient  who  has  this  lesion  is  charac- 
teristic, for  there  is  present  a  compensatory  straightening  of  the 
spine  above  with  a  secondary  flattening  of  the  thorax.  Frequent 
allusion  has  been  made  in  medical  literature  to  this  attitude  and 
it  has  been  termed  the  "flat  back".2  In  osteopathic  literature  it  is 
spoken  of  as  "the  straight  spine  and  the  flat  chest".  The  scap- 
ulae are  often  winged,  the  antero-posterior  diameter  of  the  thorax 
is  lessened,  the  transverse,  widened.3 

The  significance  of  the  extension  lesion  of  the  sacrum  can  be 
comprehended  only  when  with  a  pelvic  model  in  hand,  one  may 
demonstrate  the  narrowing  of  the  outlet  that  is  thus  produced  and 
realize  what  a  bearing  it  would  have  upon  the  health  of  the  pelvic 
tissues  and  also  what  a  hindrance  it  would  offer  to  parturition. 
When  the  sacro-sciatic  ligaments  become  lax,  the  soundness  of 
the  pelvic  floor  is  endangered,  it  sags,  and  congestion  results,  fol- 
lowed naturally  by  inflammation  of  some  of  the  pelvic  viscera,  the 
prostate  gland,  uterus  and  appendages,  rectum,  or  bladder. 

An  almost  constant  symptom  of  sacral  lesion  is  backache. 
Nervous  disturbances  follow  rigidity  of  any  articulation  which 
directly  or  indirectly  supports  the  spinal  cord,  hence,  immobiliza- 

1.  I  am  indebted  to  Dr.  Lew  A.  May  for  calling  my  attention  to  the 
effects  of  fatigue  and  riding  upon  the  ligamentous  and  muscular  tone  of  the 
articulation  with  the  subsequent  extension  lesion  of  the  sacrum.     Dr.  May 
has  also  offered  one  of  the  corrective  movements  which  follow. 

2.  See  Lovett,  ibid.,  pg.  181. 

3.  A  fuller  discussion  of  the  thoracic  changes  will  be  found  in  the  follow- 
ing chapter. 


136  OSTEOPATHIC  MECHANICS 

tion  of  the  sacrum,  partial  or  complete,  or  of  one  sacro-iliac  joint, 
predisposes  to  nervous  maladies  for  with  each  step  an  irritative 
jar  shocks  the  delicate  nervous  tissues  above. 

The  diagnosis  of  an  extension  lesion  is  established  by  the 
following  signs : 

1.  Restricted  movement  in  both  sacro-iliac  articulations. 

2.  Flattening  of  the  innominates  posteriorly. 

3.  Widening  of  the  distance  between  the  posterior  superior 
spines  in  comparison  with  the  average  measurement  between  these 
processes. 

4.  Relaxed  sacro-sciatic  ligaments. 

5.  The   presence   of  counterbalancing  lesions;   the   straight 
spine,  which  is  characterized  by  a  posterior  lumbar  area,  a  flat 
dorsal  area,  and  depressed  ribs. 

CORRECTIVE  MOVEMENTS 

THE  PRINCIPLES  OF  CORRECTION  FOR  AN  EXTENSION  LESION 
OF  THE  SACRUM  ARE  FLEXION  OF  THE  SACRUM  OR  EXTENSION  OF 
BOTH  INNOMINATES. 

Preliminary  treatment  may  be  given  before  correction  of  the 
lesion  is  attempted.  Each  innominate  should  be  moved  in  an 
attempt  to  stretch  the  ligaments  of  the  sacro-iliac  articulation. 
The  muscles  of  the  hip-joint  should  be  stretched  passively  and  the 
lumbar  area  should  receive  some  attention.  Since  the  lumbar 
vertebrae  have  moved  backward,  they  should  be  given  extension. 

II.  HAMSTRING  MOVEMENT. — The  patient,  B,  is  assumed  to 
have  an  extension  lesion  of  the  sacrum.     He  is  asked  to  sit  with 
his  feet  outstretched  upon  the  table.     The  pull  of  the  hamstring 
muscles  will  fix  both  innominates.     O  stands  beside  him,  places 
one  hand  across  B's  thighs  just  above  the  knees,  the  other  against 
B's  spine  in  the  lower  dorsal  area.     He  holds  B's  legs  to  the  table 
at  the  same  time  bending  him  forward  toward  his  knees.     The 
tension  upon  the  sciatic  nerve  prevents  any  marked  flexion  but 
the  movement  may  afford  sufficient  motion  between  the  innomi- 
nates and  the  sacrum  to  effect  a  correction  of  the  lesion  after 
many  repetitions. 

The  patient  should  practice  this  movement  at  home  between 
treatments. 

III.  ACETABULAR     LEVERAGE  MOVEMENT. — B  is  assumed  to 

have  a  sacral  extension  lesion.  He  is  asked  to  lie  supine  upon  the 
table,  and  flex  his  knees  resting  his  feet  upon  the  table.  O  instructs 


OSTEOPATHIC  MECHANICS  137 

an  assistant,  C,  to  separate  B's  knees  to  an  angle  of  about  sixty 
degrees  and  then  to  carry  the  thighs  so  that  they  will  make  with 
the  horizontal  plane  of  the  supine  body  an  obtuse  angle  of  about 
one  hundred  twenty  degrees,  or  an  acute  angle  with  the  plane  of 
the  table  beneath  of  sixty  degrees.1  He  is  instructed  to  place  his 
hands  in  front  of  the  knees  to  direct  pressure  along  the  shaft  of 
the  femur  toward  the  acetabulum. 

O  stands  at  the  right  of  B  and  faces  B's  feet.  O  reaches 
across  the  table  with  his  left  hand  and  passes  it  under  B's  left 
hip  with  the  purpose  of  grasping  the  tuberosity  of  the  left  ischium, 
resting  his  forearm  at  the  same  time  strongly  against  the  left 
iliac  crest.  With  his  right  hand  he  takes  hold  of  B's  right  tuber- 
osity and  presses  against  the  right  ilium  with  the  forearm.  At  the 
time  that  C  directs  strong  pressure  against  B's  knees,  O  attempts 
to  pull  apart  the  tuberosities  and  push  medially  and  backward 
against  the  ilia. 

It  is  often  helpful  to  place  a  small  hard  pillow  under  the 
lumbar  area  as  low  as  the  -base  of  the  sacrum,  to  assist  in  forcing 
the  base  into  flexion. 

This  movement  brings  out  the  fact  that  in  an  articulation  it 
is  often  possible  to  use  either  bone  of  that  joint  as  the  power  arm 
of  a  lever. 

IV.  ISCHIAL  SEPARATING  MOVEMENT. — Ask  the  patient,  B, 
to  lie  prone  across  the  table  so  that  his  legs  drop  off  on  one  side 
and  his  head  and  shoulder  girdle  on  the  other  side.  An  assistant, 
C,  puts  pressure  against  the  base  of  the  sacrum  above  the  second 
sacral  segment.  O  puts  the  heel  of  each  hand  against  the  medial 
surface  of  the  tuberosity  of  each  ischium  to  push  the  tuberosities 
outward  and  downward  while  C  holds  firmly  the  base  of  the  sacrum 
as  if  to  flex  that  bone  forward.  This  movement  should  be  repeated 
five  or  six  times  at  each  treatment. 

Since  the  lesion  is  of  gradual  production,  with  counterbalan- 
cing changes  in  posture  developing  at  the  same  time,  there  is  no 
open  sesame  to  an  immediate  correction.  The  fibres  of  the  lowest 
fasciculi  of  the  sacro-spinalis  (erector  spinse,  O.  T.)  are  stretched 
and  atrophied;  the  complexity  of  action  of  the  upper  divisions  of 
the  same  muscle  is  disturbed,  and  thereby  .one  of  the  greatest 
factors  in  the  maintenance  of  good  position  becomes  inoperative. 
Tone  must  be  restored  to  enable  it  to  perform  its  part  in  holding 

1.  In  explanation  of  femur  leverage  affecting  movement  in  the  sacro-iliac 
articulation  it  may  be  pointed  out  that  the  acetabulum  is  diagonally  anterior 
and  inferior  to  the  axis  of  motion. 


138  OSTEOPATHIC  MECHANICS 

the  body  upright  and  in  regaining  the  normal  position  of  the  line 
of  gravity.  These  patients  require  considerable  tonic  treatment 
and  their  cooperation  must  be  secured  in  keeping  a  careful  guard 
upon  themselves  that  they  shall  not  return  into  faulty  habits  of 
attitude.  They  need  to  be  taught  how  to  stand,  how  to  sit,  how 
to  breathe,  and  how  to  curb  their  ambitions  until  the  physical  body 
is  equal  to  the  tasks  they  have  appointed  unto  themselves.  Fol- 
lowing the  overcoming  of  the  extension  lesion  of  the  sacrum,  the 
straight  spine,  and  the  flat  chest,  the  patients  should  pursue 
for  a  long  time  gymnastic  work  of  the  general  kind  to  keep  a  bal- 
ance of  power  in  the  muscular  system. 

EXTENSION  OF  THE  OS  COX^ 

Since  the  sacrum  is  the  movable  bone  in  the  sacro-iliao  articu- 
lation, extension  of  the  innominate  is  accomplished  by  prevention 
of  its  participation  in  the  general  movement  of  flexion  upon  the 
heads  of  the  femurs.  When  the  sacrum  and  the  other  innominate 
move,  the  one  held  immobilized  becomes  strained  at  the  articula- 
tion and  a  lesion,  called  the  posterior  innominate,  results. 

EXPERIMENTAL  PALPATION,  L. — Choose  a  subject,  B,  who  has 
flexible  sacro-iliac  articulations,  and  ask  him  to  sit  upon  the  table 
with  his  right  ischium  upon  the  table,  the  right  leg  outstretched 
and  slightly  lateral  to  the  right  of  a  line  perpendicular  to  the  mesial 
plane  of  the  body;  let  his  left  ischium  and  leg  be  free  of  the  table, 
the  weight  resting  easily  upon  the  toes  of  the  left  foot  which 
should  rest  upon  the  floor  or  a  stool.  An  assistant,  C,  standing 
to  the  right  of  B,  may  place  his  right  hand  on  B's  thigh  above  the 
knee,  pressing  it  down  upon  the  table  while  with  his  left  hand 
against  the  lower  thoracic  vertebrae  of  B's  spine,  he  carries  B  for- 
ward in  flexion  and  holds  him  there  while  O  makes  careful  palpa- 
tion of  the  posterior  surfaces  of  the  ilia  and  the  sacrum.  O  should 
find  that  the  posterior  superior  spinous  process  of  the  right  in- 
nominate seems  more  prominent  than  the  left  one.  He  should 
also  notice  by  comparison  that  the  distance  between  that  spinous 
process  and  a  definite  point  upon  the  sacrum  is  less  than  the  dis- 
tance between  that  same  point  and  the  posterior  superior  spinous 
process  of  the  left  innominate.  With  a  steel  tape  in  hand  he  should 
confirm  his  determinations  by  palpation. 

Let  B  resume  the  erect  position,  either  standing  or  sitting,  and 
measurements  taken  in  the  same  way  will  show  that  in  the  experi- 


OSTEOPATHIC  MECHANICS 


139 


ment  the  right  ilium  glided  backward  and  medially  upon  the 
sacrum  at  the  sacro-iliac  articulation. 

This  experiment  proves  that  when  the  right  innominate  is 
fixed  as  by  the  pull  of  the  hamstring  muscles,  flexion  of  the  sacrum 
and  the  other  innominate,  as  one  bone,  upon  the  immobilized 
innominate,  produces  experimentally  the  posterior  innominate 
lesion.1  Strain  or  any  other  causative  factor  may  in  this  manner 
produce  the  lesion. 

A  posterior  innominate  lesion  is  a  subluxation  of  the  sacro- 


FIG.  51. — Illustrating  the  experimental  production  of  a  posterior  innominate  lesion. 


1.  This  lesion  should  most  properly  be  termed  an  extension  lesion  of  the 
innominate  but  the  time  does  not  seem  to  be  right  for  this  innovation. 


140 


OSTEOPATHIC  MECHANICS 


FIG.  52. — Patient  with  marked  evidence  of  a  posterior  innominate  lesion  on  the  right  side. 

iliac  joint  in  which  the  articulation  is  immobilized  in  a  position  of 
flexion  of  the  sacrum  upon  one  innominate  or  of  the  innominate 
in  extension  upon  the  sacrum. 


EXAMINATION   OF  A  PATIENT 

It  is  to  be  assumed  that  the  patient,  B,  presents  himself  with 
symptoms1  which  would  lead  to  the  supposition  that  he  has  a 
right  posterior  innominate  lesion,  and  that  upon  applying  the  test2 
for  motion,  none  is  found  in  the  right  sacro-iliac  articulation. 

1.  Pelvic  disturbances,  sciatica,  orchitis,  weak  ankle,  flat  foot,  metalar- 
a,  varicose  veins. 

2.  See  page  129. 


OSTEOPATHIC  MECHANICS 


141 


B  is  asked  to  bare  the  lower  part  of  his  back  for  inspection. 
If  the  lesion  is  present,  it  is  usual  for  the  right  posterior  superior 
spinous  process  of  the  innominate  to  be  markedly  prominent  in 
the  plane  of  the  back.  Palpation  for  comparison  of  the  two  pos- 
terior superior  spinous  processes  of  the  ilia  shows  that  the  one  in 
lesion  is  more  prominent  posteriorly  than  the  other;  that  in  the 
matter  of  level,  horizontally  considered,  it  is  lower  than  the  left. 

B  is  asked  to  stand  and  palpation  is  made  of  the  upper  bor- 
ders of  the  pubes;  when  lesion  is  present,  the  right  pubic  bone  is 
slightly  higher  and  a  little  backward  of  the  other.  Palpation  per 
rectum  will  show  that  the  right  sacro-tuberous  and  sacro-spinous 
ligaments  are  taut. 

With  a  steel  tape,  measurements  should  be  made  as  in  the 
experiment1  above  to  show  that  the  right  superior  spinous  process 


FIG.  53. — Patient  with  a  right  posterior  innominate,  showing  the  relative  heights  of  the 
posterior  superior  spines  by  the  crosses. 

1.  Experimental  palpation,  L,  page  138. 


142 


OSTEOPATHIC  MECHANICS 


FIG.  54. — Side  view  of  the  innominate  in  its  normal  position  in  relation  to  the  sacrum. 
The  dotted  lines  indicate  the  directions  in  which  this  bone  is  most  likely  to  be  misplaced.  The 
blue  dotted  line  indicates  the  position  the  os  coxae  would  take  in  a  posterior  lesion;  the  red,  in 
an  anterior  lesion. — (F.  P.  MILLA.BD.) 


OSTEOPATHIC  MECHANICS  143 

is  nearer  to  a  definite  point  upon  the  posterior  surface  of  the 
sacrum  in  the  mid-line  than  is  the  left. 

In  the  absence  of  other  lesions,  such  as  curvature,  ankylosis  of 
the  hip,  muscular  contracture,  etc.,  there  are  certain  auxilliary 
signs  that  are  ordinarily  present  in  a  case  having  a  posterior  in- 
nominate lesion.  They  are  not  reliable  when  considered  alone 
and  no  lesion  should  be  diagnosed  without  the  other  signs  being 
present.  Both  legs  should  be  flexed,  extended,  rotated,  and  cir- 
cumducted  before  the  first  of  these  signs  should  be  sought.  The 
legs  may  then  be  brought  together  upon  the  table  and  the  length 
of  the  heels  compared.  The  one  on  the  side  of  the  posterior 
innominate  will  usually  be  shorter. 

If  the  distance  between  a  definite  point  upon  the  sternum 
and  each  anterior  superior  spinous  process  be  measured,  it  will  be 
found  that  the  distance  to  the  innominate  in  lesion  is  less.  The 
distance  to  the  internal  malleolus  of  the  same  side  will  be  less  than 
the  distance  to  that  of  the  other  ankle. 

Tenderness  and  pain  upon  pressure  is  a  fairly  constant  symp- 
tom but  as  pain  is  often  due  to  sensations  referred  from  viscera 
of  lower  sensibility,1  it  has  not  diagnostic  accuracy.2 

Upon  the  presence  of  the  following  unvarying  signs  may 
diagnosis  be  made : 

1.  Restricted  motion  in  the  joint. 

2.  Prominence  of  the  posterior  superior  spinous  process. 

3.  Distance  from  that  process  to  the  second  sacral  spinous 
process  is  less  than  the  distance  between  the  same  two  points  upon 
the  left. 

4.  Right  sacro-sciatic  ligaments  taut. 

CORRECTIVE  MOVEMENTS 

THE  PRINCIPLES  OF  .CORRECTION  FOR  A  POSTERIOR  INNOMINATE 
LESION  ARE  EXTENSION  OF  THE  SACRUM  OR  FLEXION  OF  THE  IN- 
NOMINATE. 

GENERAL  RULES. — ALL  MOVEMENTS  MUST  CARRY  THE  BONE 
THAT  IS  USED  AS  A  LEVER  IN  ROTATION  ABOUT  THE  AXIS  OF  MOTION, 


1.  Henry  Head,  "On  Disturbances  of  Sensation"  in  "Brain",  1893,  vol. 
xvi,  p.  1;   also  in  sequent  numbers,  1894,  1896,  1900,  etc. 

2.  Richard  C.  Cabot,  "Differential  Diagnosis,"  1912,  W.  B.  Saunders 
Co.,  publishers,  presents  a  masterly  review  of  pain  as  a  diagnostic  sign. 


144 


OSTEOPATHIC  MECHANICS 


FIG  55. — Anterior  view  of  the  pelvis  wlffrrtiC  innominate  in  normal  position.  A.B.  is  the 
transverse  axis  upon  which  the  innominate  glides.  The  red  dotted  line  indicates  the  position 
which  the  innominate  would  assume  in  a  posterior  lesion;  the  blue  dotted  line,  an  anterior  in- 
nominate lesion. — (F.  P.  MILLARD.J 


OSTEOPATHIC  MECHANICS 


145 


FIG.  56 — Posterior  view  of  the  ossa  coxae  in  their  normal  relationship  to  the  sacrum.  The 
dotted  lines  show  the  innominate  rotated  forward  and  backward  on  the  transverse  axis  which 
passes  through  the  second  sacral  segment.  (F.  P.  MILLARD.) 


146 


OSTEOPATHIC  MECHANICS 


A    TRANSVERSE    ONE    INTERSECTING    THE    SACRO-ILIAC    ARTICULAR 
SURFACES  AND  THE  SECOND  SACRAL  SEGMENT. 

THE  DIRECTION  OF  THE  PLANES  OF  THE  ARTICULATING  SUR- 
FACES MUST  BE  KEPT  BEFORE  THE  MIND  CONTINUALLY  THAT  NO 
MOVEMENT  SHALL  JAM  THESE  PLANES. 

Flexion  of  the  innominate  is  a  movement  of  rotation  and 
secondary  outward  gliding,  and  the  mechanical  principle  involved 
is  that  of  the  wheel  and  axle.  The  points  of  attack  about  the  in- 
nominate are  the  most  advantageous  leverages  by  which  this 
movement  may  be  made  effective  in  adjusting  lesions  of  the  sacro- 
iliac  joint. 

For  the  correction  of  the  posterior  innominate  lesion,  the 
following  points  of  attack  may  be  noted:  the  tuberosity  of  the 
ischium,  the  posterior  superior  spinous  process  and  the  adjacent 
crest  of  the  ilium,  the  anterior  border  of  the  ilium  through  the 
following  muscles,  sartorious,  direct  head  of  the  rectus  femoris, 
tensor  fasciae  latae,  and  the  acetabulum  by  its  contact  with  the 


FIG.  57. — Manner  of  correcting  a  posterior  innominate  lesion  by  the  wheel  and  axle  method, 
also  a  method  of  taking  hold  of  the  innominate  for  the  purpose  of  putting  the  sacro-iliac  joint 
through  its  normal  movements. 


OSTEOPATHIC  MECHANICS  147 

femur  through  the  shaft  of  which,  according  to  the  angle  it  makes 
with  the  plane  of  the  trunk,  may  be  directed  a  force  which  will 
rotate  the  innominate  backward  and  inward  or  outward  and  for- 
ward. 

V.  ROTATION  LATERAL  MOVEMENT. — Let  B,  who  is  assumed 
to  have  a  right  posterior  innominate  lesion,  lie  upon  his  left  side 
on  the  table  facing  O  who  stands  beside  the  table.     O  should  flex 
B's  left  knee  and  place  it  against  O's  thigh  to  hold  firmly  part  of 
the  pelvis.     O  flexes  B's  right  leg  at  the  knee  and  places  the  knee 
against  his  sternum,  so  that  B's  thigh  is  at  right  angles  to  the 
plane  of  his  trunk.     O  places  the  heel  of  his  left  hand  against  the 
anterior  surface  of  the  right  tuberosity,  the  palm  of  the  right  hand 
against  the  posterior  superior  spinous  process  and  the  crest  of  the 
ilium  adjacent.     0  now  combines  simultaneously  a  firm,  unswerv- 
ing pressure  against  B's  right  knee  in  a  straight  line  forward,  while 
he  pushes  backward  on  the  tuberosity  and  pulls  forward  on  the 
posterior  upper  part  of  the  ilium  in  the  effort  to  secure  a  rotation  of 
the  innominate  forward  and  outward. 

O  may  continue  this  pressure  constantly  for  a  few  moments 
with  an  additional  excess  of  force  at  its  conclusion;  he  may  apply 
the  pressures  with  vibration  for  some  moments,  or  he  may  repeat, 
with  intermediate  relaxation,  the  efforts  at  correction. 

VI.  SUPINE  ROTATION  MOVEMENT. — Let  B,  having  the  same 
lesion  as  above,  lie  upon  his  back  on  the  table,  O  standing  to  his 
right  side,  and  facing  the  head  of  the  table.     0  pulls  B  laterally 
toward  him  until  the  tuberosity  of  the  right  ischium  escapes  the 
table.     He  flexes  B's  right  leg  to  a  right  angle  and  carrying  it 
laterally  until  the  femur  lies  in  a  plane  parallel  to  the  sacro-iliac 
articulation,  he  places  the  knee  under  his  right  axilla.     O  places 
his  hands  over  and  back  of  B's  hip  until  they  can  exert  a  forward 
pull  upon  the  posterior  third  of  the  crest  of  the  right  ilium.     The 
two  pressures  are  made  coincidentally,  downward  and  backward 
upon  the  femur,  and  upward  and  forward  upon  the  iliac  crest; 
thus,  two  points  of  attack  are  made  use  of  in  this  movement. 

VII.  UPRIGHT  ROTATION  MOVEMENT. — Ask  B  to  stand  with 
the  left  innominate  and  sacrum  against  a  door  jamb.     He  is  in- 
structed to  flex  his  right  knee  to  a  right  angle  with  his  body  wall. 
O  carries  the  flexed  knee  laterally  a  little  and  rests  the  knee  against 
his  own  left  thigh  or  hip  bone.     He  takes  hold  of  the  right  tuber- 
osity to  push  it  backward  while  with  his  left  hand  he  pulls  upon 
the  posterior  third  of  the  iliac  crest  to  bring  it  forward  and  out- 
ward. 

The  principle  applied  in  this  movement  is  exactly  the  same 


148 


OSTEOPATHIC  MECHANICS 


FIG.  58. — Illustrating  the  scissors  movement  for  the  correction  of  a  posterior  innominate 
lesion. 

as  in  the  rotation  lateral  movement  save  that  the  position  of  B's 
body  is  upright  instead  of  lateral.1 

VIII.  SCISSORS'  MOVEMENT. — Ask  B  to  lie  prone  upon  the 
table.  O  stands  to  his  left  and  places  his  left  hand  upon  the  lower 
part  of  B's  sacrum  to  hold  it  as  a  fixed  point  against  which  the 
right  innominate  may  be  rotated  by  a  pull  upon  the  anterior  supe- 
rior spine  and  adjacent  osseous  surfaces.  0  reaches  across  and 
lifts  B's  right  leg  by  taking  hold  of  it  above  the  knee.  He  carries 
the  thigh  across  the  left  one  and  with  recurring  tension  and  re- 
laxation exerts  a  pull  upon  the  innominate  which  is  sufficient  to 
adjust  it. 

The  left  hand  may  be  placed  against  the  posterior  superior 
spine  to  add  to  the  pulling  of  the  thigh  muscles  described  above, 
a  thrust  in  a  direction  to  push  the  ilium  outward  and  forward.2 

1.  The  student  should  plan  in  this  manner  how  he  may  vary  corrective 
movements  by  changing  the  patient's  position.     In  the  case  of  the  scissors' 
movement,  the  patient  might  lie  upon  the  floor,  or  stand  against  the  door- 
jamb,  facing  it  and  the  movement  would  be  practically  unvaried.     It  is  essen- 
tial to  know  the  principles  of  correction  and  have  some  experience  in  handling 
the  body  mass  of  patients  before  it  is  possible  to  combine  position  and  leverages 
in  the  perfection  of  an  elaborate  technique. 

2.  Dr.  Kendall  L.  Achorn,  in  the  "Jour,  of  the  A.  O.  A.",  June,  1913, 
pg.  617,  (b),  described  a  vibratory  method  of  correcting  this  lesion  which  he 
uses  instead  of  the  scissors'  movement.     It  consists  in  applying  vibration  to 
the  posterior  superior  spine  in  the  right  direction  for  adjustment. 


OSTEOPATHIC  MECHANICS  149 

IX.  LEG-SWINGING  MOVEMENT. — -Ask  B  to  lie  supine  upon  the 
table,  with  his  right  innominate  projecting  beyond  the  edge  of 
the  table.     O  stands  to  his  right  and  reaches  under  with  his  left 
hand  until  he  can  grasp  the  tuberosity  of  the  right  ischium.     He 
lets  the  posterior  superior  spine  and  the  adjacent  crest  of  the  ilium 
rest  against  his  left  forearm.     With  the  right  hand  he  carries  B's 
right  leg  off  from  the  table  and  presses  downward  upon  it  above  the 
knee  to  cause  a  tension  in  the  muscles  attached  to  the  anterior 
superior   spine   and   adjacent   surfaces.     Pulling   backward   and 
upward  upon  the  tuberosity  and  iliac  crest,  and  pushing  downward 
and  outward  upon  B's  thigh,  by  repeated  attempts,  or  by  steady 
action  with  an  increase  in  force  at  conclusion,  the  lesion  may  be 
adjusted. 

X.  SACRUM-LEVERAGE  MOVEMENT. — Ask  B  to  lie  prone  upon 
the  table  with  the  left  leg  off  the  table,  its  weight  resting  easily 
upon  the  toes.     O  stands  beside  the  table  on  B's  left.     He  places 
the  heel  of  his  left  hand  against  the  right  posterior  superior  spine, 
his  right  hand  against  the  lower  part  of  the  sacrum  to  assist  B  in 
its  extension.     B  is  asked  to  bring  himself  back  in  extension  as 
far  as  possible  without  lifting  the  pelvis  from  the  table.     This 
may  be  repeated  several  times  at  one  treatment. 

In  some  cases  it  is  better  for  O  to  place  both  hands  over  the 
right  posterior  superior  spine  and  when  B  brings  the  sacrum  back 
in  extension,  after  repeated  efforts  making  certain  that  the 
articulation  has  been  prepared,  give  a  direct  and  sudden  increase 
of  force  against  the  ilium  for  adjustment.  It  may  require  thirty 
foot-pounds  of  power  to  overcome  the  lesion. 

This  movement  without  the  assistance  of  O  may  be  taken  as 
an  exercise  for  all  patients  who  have  shown  any  improvement  in 
the  motion  of  the  posteriorly  lesioned  sacro-iliac  articulation. 

AFTER-TREATMENT 

This  is  largely  that  of  prevention  of  recurrence.  It  is  un- 
deniably true  that  no  osseous  lesion  exists  without  atony  of  the 
stretched  muscle  tissues  and  without  contracture  of  the  shortened 
fasciculi.  Unequal  muscular  tension  signifies  disturbed  equilib- 
rium and  the  lower  down  this  loss  of  symmetry  occurs,  the  more 
apt  is  it  to  recur  through  the  influence  of  weight  carriage.  It 
is  for  this  reason  that  the  patients  having  innominate  lesions 
should  be  advised  to  study  the  habits  of  their  daily  lives  to  find 
out  what  actions  may  seem  to  induce  a  recurrence  or  strain  the 


150 


OSTEOPATHIC  MECHANICS 


joint.  From  knowledge  of  previous  cases  the  physician  should 
advise  the  patient  to  sit  erect  before  turning  over  in  bed,  to  avoid 
standing  upon  one  foot,  crossing  the  knees,  walking  with  heels  of 
unequal  height,  stooping  to  one  side,  and  bending  upon  one  kiu-c. 

FLEXION  OF  THE  OS  COX^E 

Flexion  of  the  innominate  is  accomplished  by  immobilizing 
the  os  coxae  and  moving  the  sacrum  and  other  innominate,  as 
one,  backward  in  extension.  If  strain  or  infective  process  should 
cause  a  permanent  immobilization  of  the  articulation,  an  anterior 
innominate  lesion  would  be  produced. 

EXPERIMENTAL  PALPATION,  M. — Ask  the  subject,  B,  to  lie 
prone  upon  the  table,  with  his  left  leg  and  innominate  dropping 
off  the  edge  of  the  table  but  resting  the  weight  in  ease  upon  the 
foot  on  the  floor.  With  his  hands  palm  downward  upon  the  table, 
B  raises  himself  backward  in  extension  while  O  palpates  the  sacro- 
iliac  articulations,  comparing  the  motion  in  both  joints,  the  meas- 
urements between  the  posterior  superior  spines  and  a  certain 


FIG.  59. — Illustrating  the  experimental  production  and  palpation  of  an  anterior  innominate 
lesion. 


OSTEOPATHIC  MECHANICS  151 

point  upon  the  sacrum,  and  the  levels  of  the  bony  surfaces  before 
thet  motion  begins  and  at  its  termination.  With  a  steel  tape, 
while  B  holds  the  position  of  flexion,  O  verifies  his  conclusions 
arrived  at  by  palpation,  which  may  be  summarized  as  follows: 

The  sacrum  and  left  innominate  have  moved  as  one  bone 
backward  upon  the  right  innominate  above  the  axis  of  rotation 
and  forward  upon  the  innominate  below  the  axis  of  motion. 

The  distance  between  the  posterior  superior  spine  of  the  right 
iluim  and  the  spinous  process  of  the  second  sacral  segment  is 
greater  than  the  distance  between  the  same  corresponding  points 
upon  the  left  side. 

In  forward  rotation  of  the  innominate,  the  distance  between 
the  coccygeal  extremity  of  the  sacrum  and  the  ischium  must  be 
lessened,  causing  the  sacro-sciatic  ligaments  to  become  lax.  The 
forward  rotation  would  also  depress  the  left  side  of  the  pubic 
symphysis. 

The  anterior  innominate  lesion  may  be  defined  as  an  immobili- 
zation of  the  sacro-iliac  articulation  in  the  position  of  extension 
of  the  sacrum  or  flexion  of  the  innominate. 

Its  diagnosis  is  established  by  the  presence  of  the  following 
signs : 

1.  Flattening  of  the  posterior  superior  spine. 

2.  Restricted  motion  in  the  articulation. 

3.  Distance  between  posterior  superior  spine  and  a  fixed 
point  on  sacrum  is  less  than  upon  the  opposite  side. 

4.  Sacro-sciatic  ligaments  of  same  side  relaxed. 

0.  Corresponding  side  of  os  pubis  depressed. 

The  following  auxilliary  signs  may  or  may  not  be  present: 

1.  Tenderness  and  pain  upon  pressure  over  the  articulation. 

2.  Distance  between  a  fixed  point  on  the  sternum  and  the 
anterior  superior  -spines  of  the  ilia  greater  on  the  lesioned  side. 

3.  Measurement  of  the  apparent  length  of  the  sides  by  com- 
paring the  heels,  shows  the  heel  upon  the  side  of  the  lesioned 
innominate  longer. 

4.  Measurement  between  the  same  fixed  point  on  the  sternum 
and  the  two  malleoli  shows  a  greater  distance  on  the  side  of  the 
lesioned  innominate. 

The  examination  of  a  patient  having  the  symptoms1  of  which 
those  afflicted  with  this  lesion  complain,  should  be  made  after  the 
manner  of  examination  for  a  posterior  innominate  with  the  differ- 
ential diagnosis  established  by  the  presence  of  the  unfailing  signs. 

1.  The  anterior  innominate  lesion  is  the  indirect  etiologic  foundation  for 
conditions  which  express  themselves  by  the  following  symptoms:  nervous 
disturbances,  pelvic  misplacements,  amenorrhea,  dysmenorrhea,  cystitis, 
pain  in  the  knee,  and  weakness  of  the  ankle  and  foot. 


152 


OSTEOPATHIC  MECHANICS 


CORRECTIVE  MOVEMENTS 

THE  PRINCIPLES  OF  CORRECTION  FOR  AN  ANTERIOR  INNOMI- 
NATE LESION  ARE  EXTENSION  OF  THE  SACRUM  OR  FLEXION  OF  THE 
INNOMINATE. 

GENERAL  RULES. — SINCE  THE  MOTION  OF  THE  SACRO-ILIAC 
ARTICULATION  IS  ROTARY  AND  ARTHRODIAL  IN  CHARACTER,  ALL 
AD.7USTIVE  MOVEMENTS  MUST  HAVE  FOR  THEIR  PURPOSE  BACK- 
WARD ROTATION  AND  INWARD  GLIDING  OF  THE  INNOMINATE. 

The  points  of  attack  upon  the  innominate  for  correction  of 
the  anterior  innominate  lesion,  are  the  anterior  superior  spine, 
the  tuberosity  of  the  ischium,  the  hamstring  muscles  pulling  upon 
the  ischium,  and  the  femur  in  the  acetabulum  at  an  obtuse  angle 
to  the  plane  of  the  body  wall. 

XI.  BACKWARD  ROTATION  MOVEMENT. — Let  the  patient,  B, 
who  is  assumed  to  have  an  anterior  innominate  lesion  upon  the 
right,  lie  upon  his  left  side  on  the  table  facing  O  who  stands  beside 
him.  O  flexes  B's  knees  at  obtuse  angles,  places  the  right  against 
the  upper  part  of  his  sternum,  the  left  against  his  thigh  to  hold 


FIG.  60. — Illustrating  the  wheel  and  axle  method  of'correction  of  an  anterior  innominate 
lesion,  showing  the  angle  which  the  femur  should  make  with  the  horizontal  plane  of  the  table. 


OSTEOPATHIC  MECHANICS 


153 


FIG.  61. — Illustrating  a  movement  of  correction  for  an  anterior  innominate  lesion. 

the  pelvis  firmly.  He  grasps  the  right  ischial  tuberosity  to  pull 
it  forward,  and  places  the  heel  of  his  right  hand  against  the  anterior 
superior  spine  of  B's  right  innominate  to  rotate  it  backward. 
Pressure  is  made  simultaneously  against  the  three  points  of  attack, 
each  movement  being  in  a  different  direction  from  the  other  two. 
The  pressure  may  be  increased  at  its  conclusion,  it  may  be  given 
in  vibratory  fashion,  or  it  may  be  given  with  alternate  strong 
force  and  relaxation.  Adjustment  does  not  usually  occur  with  any 
sound  whatsoever,  and  verification  of  correction  must  be  had  by 
the  absence  of  the  diagnostic  signs. 

B's  anterior  innominate  lesion  may  also  be  corrected  by  the 
same  procedure  when  he  lies  upon  his  back  on  the  table,  with  the 
right  innominate  free  of  the  table.  The  knee  of  the  right  innomi- 
nate is  placed  in  O's  right  axilla,  the  thigh  flexed  at  an  obtuse 
angle  with  the  plane  of  the  trunk  and  the  shaft  of  the  femur 
abducted  until  it  lies  in  a  plane  parallel  to  the  articular  surfaces 
of  the  right  sacro-iliac  joint. 


154  OSTEOPATHIC  MECHANICS 

XII.  UPRIGHT  BACKWARD  ROTATION  MOVEMENT. — The  pa- 
tient, B,  is  directed  to  stand  against  the  door-jamb  with  the  left 
innominate  and  the  sacrum  resting  against  the  jamb  as  a  fixed 
point  against  which  to  rotate  the  right  innominate  as  in  the  above 
manner. 

XIII.  WEIGHT  PULLING  MOVEMENT.! — Ask  the  patient,  B, 
to  lie  across  the  table  prone,  with  the  head  and  shoulder  girdle 
hanging  free  upon  one  side,  with  the  anterior  superior  iliac  spines 
resting  on  the  table  on  the  opposite  side,  the  pubes  and  thighs 
being  free  of  the  table.     O  stands  behind  and  to  the  right  of  B 
and  steps  with  his  left  foot  between  B's  legs,  placing  his  right  hand 
upon  the  base  of  B's  sacrum.     With  his  left  hand  he  grasps  B's 
right  leg  at  the  ankle  and  raises  it  until  it  is  at  a  right  angle  with 
B's  thigh.     O  then  puts  his  right  tibia  in  the  bend  of  B's  knee. 
O  lets  a  small  amount  of  weight  rest  against  B's  leg  to  abduct  it 
until  the  shaft  of  the  femur  lies  in  a  plane  parallel  to  the  sacro- 
iliac  joint.     O  then  puts  a  considerable  amount  of  pressure  sudden- 
ly down  upon  B's  leg  to  pull  in  backward  rotation  the  right 
innominate,  meanwhile  holding  firmly  the  sacrum  as  a  fixed  point. 


FIG,  62. — Illustrating  the  weight  pulling  method  of  adjusting  an  anterior  innominate 
lesion. 


1.  This  movement  has  been  well  described  and  illustrated  by  Dr.  Reginald 
Platt  of  Minneapolis  in  current  osteopathic  literature. 


OSTEOPATHIC  MECHANICS  155 

XIV.  REENFORCED  FIXATION  MOVEMENT.  1 — Ask  the  patient 
B,  to  lie  upon  his  left  side  upon  the  table  and  carry  the  shoulders 
prone  upon  the  table  by  dropping  the  left  arm  off  from  the  table 
behind  him.     This  extreme  rotation  of  the  trunk  is  for  the  purpose 
of  adding  a  secondary  fixation  of  the  sacrum  by  the  pull  of  the 
lumbosacral  and  ilio-lumbar  ligaments  of  the  right  side. 

0  stands  behind  B  and  places  his  right  knee  against  the  base 
of  B's  sacrum  to  make  of  it  a  fixed  point.  0  then  reaches  over  B 
and  takes  hold  of  his  right  leg  at  the  knee,  flexes  it  at  an  obtuse 
angle  with  the  plane  of  the  body  wall,  and  puts  a  great  deal  of 
strength  into  pulling  backward  upon  the  knee  while  raising  it 
upward  from  the  table  and  outward  from  the  mesial  plane  of  the 
body.  O  may  place  his  left  hand  or  his  lateral  thoracic  wall 
against  B's  back  to  assist  in  maintaining  the  fixation  of  the  sacrum 
against  which  the  innominate  is  rotated. 

The  movement  should  not  be  repeated  more  than  twice  at  a 
treatment  for  it  is  one  of  exceedingly  great  force  and  should  be 
used  with  caution. 

XV.  SACRAL  FLEXION  MOVEMENT. — Let  B  sit  upon  the  table 
with  his  right  leg  outstretched,  the  left  leg  dropped  off  the  side  of 
the  table  and  the  left  innominate  clear  of  the  table  at  the  ischial 
tuberosity.     O  stands  to  the  left  of  B  and  places  his  right  hand 
upon  B's  lower  thoracic  area,  his  left  hand  across  B's  thigh  just 
above  the  knee.     Under  B's  right  heel  a  brick  of  four  to  six  inches 
may  be  placed  to  raise  the  heel  and  to  increase  the  pull  of  the  ham- 
string muscles  upon  that  side. 

O  bends  B  forward  in  flexion  to  move  the  sacrum  and  other 
innominate  as  one  upon  the  innominate  in  lesion.  The  correction 
obtained  by  this  means  is  usually  gradual.  The  movement  may 
be  given  following  adjustment  to  exaggerate  the  lesion  slightly 
for  the  purpose  of  over-correction,  a  method  which  helps  to  stretch 
contracted  tissues. 

Patients  may  make  an  exercise  of  the  movement  for  home  use, 
to  keep  the  ligaments  of  the  articulation  pliable  between  treat- 
ments. 

The  patient  with  an  anterior  innominate  lesion  should  be 
warned  that  certain  movements  predispose  to  a  recurrence  of  the 
lesion  and  aggravate  the  case  before  adjustment  has  been  secured. 

1.  This  movement  is  not  recommended  for  the  use  of  the  undergraduate. 
Its  leverage  is  very  powerful  and  it  should  be  used  only  after  other  methods 
have  failed.  The  graduate  osteopath  who  has  acquired  skill  in  palpation-  so 
that  he  is  able  to  detect  the  moment  that  movement  begins  in  an  articulation 
under  correction  is  qualified  to  use  the  movement  intelligently. 


156  OSTEOPATHIC  MECHANICS 

Going  down  an  inclined  plane  as  down  hill,  down  many  flights  of 
stairs,  stepping  from  the  high  car  steps  of  street  cars  with  the  foot 
of  the  afflicted  side  in  advance,  jumping  which  brings  a  strain 
upon  both  joints  and  more  effectively  upon  the  lesioned  one, 
prolonged  sitting  in  a  backward  slumped  position  which  causes  an 
extension  of  the  sacrum,  all  are  to  be  avoided  as  much  as  possible 
before  adjustment  is  complete  and  muscular  equilibrium  has  been 
attained. 

Two  classes  of  lesions  occur  in  the  sacro-iliac  articulation, 
impaction  and  relaxation  lesions.1  The  impaction  lesion  is  difficult 
or  impossible  of  adjustment  for  when  a  thinning  of  the  cartilag- 
inous tissues  takes  place  in  the  joint  there  are  usually  irritative 
changes  going  on  which  result  in  exostoses  and  fibrous  ankylosis. 
If  the  vibratory  method  will  not  loosen  the  articulation  so  that  the 
physician  or  the  patient  can  detect  a  slight  degree  of  mobility 
after  a  few  weeks'  trial,  it  is  probably  a  joint  that  is  past  help. 
A  number  of  such  specimens,  seen  at  Wistar  Institute,  Philadelphia, 
a  part  of  the  excellent  osteological  collection  in  that  institution, 
would  prove  to  the  student  that  many  people  are  afflicted  with 
impaction  lesions  of  one  or  both  sacro-iliac  joints. 

The  hypermobile  sacro-iliac  articulation  usually  accompanies 
a  lesion  of  the  opposite  side  characterized  by  more  or  less  fixation. 
Examination  should  be  made  of  the  other  joint  to  ascertain  if  its 
motion  is  sufficient;  if  it  is  not,  treatment  should  be  given  it  to 
increase  its  mobility.  At  the  same  time  exercises  for  the  general 
strengthening  and  equilibration  of  the  spinal  muscles  should  be 
advised,  these  exercises  to  consist  in  movements  of  flexion  and 
extension  which  shall  dvelop  the  muscles  of  both  sides  of  the  back 
at  the  same  time.  A  method  which  may  be  called  the  irritative 
method,  is  often  employed  to  assist  in  fixing  the  innominate.  It 
consists  in  a  forcible  jarring  of  the  bony  surfaces  adjacent  to  the 
articulation.  The  hand  is  placed  palm  downward,  either  upon  the 
outer  surface  of  the  ilium  adjacent  to  the  posterior  superior  spinous 
process  or  upon  the  sacrum  just  internal  to  the  ilium,  and  then  the 
other  hand  doubled  in  a  fist,  strikes  the  dorsal  surface  of  the  hand 
in  position  against  the  joint  several  blows  as  hard  as  the  hand  can 


1.  See  page  10,  last  paragraph,  and  page  11,  first  paragraph. 


OSTEOPATHIC  MECHANICS  157 

bear.  This  will  set  up  in  the  joint  an  irritation  sufficient  to  shorten 
the  relaxed  ligaments. 

Recurrent  innominate  lesions,  which  simulate  the  hyper- 
mobile  articulation,  are  treated  in  much  the  same  way,  following 
adjustment  of  the  lesion.  These  cases  should  be  over-corrected 
before  the  irritative  procedure  is  begun. 

The  physician  should  not  overlook  the  possibility  of  lumbar 
lesions  accompanying  sacro-iliac  lesions  and  offering  an  etiologic 
basis  for  failure  in  adjustment.  Lesions  of  the  fourth  and  fifth 
lumbar  articulations  are  the  most  common  lesions  and  are  either 
primary  or  secondary,  and  should  be  corrected. 

Counterbalancing  lesions  occur  early  in  the  case  following  an 
innominate  lesion.  They  may  be  lateral  lumbar  lesions,  a  func- 
tional curvature  usually  of  the  lumbar  area,  or  a  secondary  lesion 
of  the  other  innominate,  of  the  opposite  type. 

SACROCOCCYGEAL  LESIONS 

The  joint  made  by  the  sacrum  and  coccyx1  is  of  the  nature  of 
a  symphysis  with  an  interarticular  cartilage  between  the  two 
bones.  The  ligaments  of  the  articulation  are  strong  but  pliable 
allowing  some  movement  in  the  joint  normally  in  the  direction  of 
flexion  and  extension.  The  upward  and  forward  pull  of  the  levator 
ani  muscle  prevents  extreme  backward  extension. 

The  lesions  of  this  joint  are  usually  the  result  of  traumatism 
or  parturition.  There  are  flexion,  extension,  rotation,  and  lateral 
bending  lesions  found  in  this  joint. 

Examination  is  made  per  rectum  for  the  purpose  of  diagnosis. 
The  normal  articulation  shows  a  fair  amount  of  motion  in  the 
direction  of  extension  and  flexion.  When  lesion  is  present,  motion 
is  restricted  or  lost;  more  or  less  tenderness  is  present  upon 
palpation  of  the  adjacent  osseous  margins  of  the  bones  in  the 
articulation.  The  patient  usually  gives  a  history  of  strain  by 
traumatism  or  in  delivery. 

A  lesion  may  be  differentiated  from  dislocation-fracture  of  the 
coccyx,  a  fairly  common  disturbance,  by  absence  of  crepitus, 
abnormal  mobility,  and  great  pain  about  the  joint. 

1.  See  Morris,  ibid.,  page  238,  ninth  paragraph. 


158  OSTEOPATHIC  MECHANICS 


FIG.  63 — Drawing  to  illustrate  the  manner  of  grasping  the  coccyx  per  rectum  for  adjust- 
ment of  sacrococcygeal  lesions. 

Coccygeal  lesion  or  dislocation  makes  difficult  rising  or  sitting 
in  chairs,  defecation,  and  forward  bending. 

An  extension  lesion  of  the  coccyx  is  one  in  which  the  sacro- 
coccygeal articulation  is  immobilized  in  the  position  of  backward 
bending.  The  principle  of  its  correction  is  forward  flexion,  accom- 
plished by  grasping  the  coccyx  between  the  thumb  on  its  posterior 
surface  and  the  index  finger  on  its  anterior  surface  through  the 
rectum,  and  after  stretching  the  tissues  about  the  joint  by  attempt- 
ing to  put  it  through  its  normal  movements,  with  a  slight  down- 
ward traction  and  with  flexion  forward,  it  is  adjusted.  Often  the 
condition  is  one  of  ankylosis  and  surgical  removal  is  indicated. 

An  anterior  coccyx  is  one  which  is  immobilized  in  the  posi- 
tion of  flexion.  Its  principle  of  correction  is  extension. 

A  rotated  coccyx  is  a  lesion  in  which  the  coccyx  is  maintained 
in  the  position  of  rotation  on  a  vertical  axis,  the  rotation  being  to 
the  right  or  to  the  left  with  additional  flexion.  Its  correction 
consists  in  retracing  the  path  taken  in  its  displacement  and  is 
accomplished  by  the  manner  offered  above  of  grasping  the  coccyx 
and  replacing  it.  Treatment  of  the  sacro-sciatic  ligaments  is 
valuable  in  preparation  for  the  adjustment. 

A  lateral  coccyx  is  one  which  is  usually  the  result  of  direct 
violence  or  it  may  be  associated  with  structural  curvature  of  the 
spine.  It  is  a  lesion  in  which  the  coccyx  is  immobilized  in  a 
position  of  lateral  gliding  upon  the  sacrum.  Its  correction  maybe 
attempted  after  the  manner  of  the  adjustment  of  the  other  lesions 
of  this  joint  and  will  be  successful  if  ankylosis  has  not  occurred. 


OSTEOPATHIC  MECHANICS  159 

PELVIC  INCLINATION 

For  two  purposes  is  consideration  given  to  the  subject  of 
pelvic  inclination,  the  first  for  the  important  bearing  it  has  upon 
the  delivery  of  the  child  and  secondly  in  reference  to  the  posture 
of  the  body  as  a  foundation  for  lateral  curvature,  scoliosis,  and 
group  lesions. 

Pelvic  inclination  is  a  term  which  is  used  to  designate  the 
relation  which  the  pelvis  bears  to  the  horizon.  The  line  by  which 
it  is  determined  is  a  line  which  is  projected  from  the  lumbosacral 
angle  to  the  upper  border  of  the  symphysis  pubis  and  the  angle 
that  line  makes  with  the  horizon  is  spoken  of  as  the  angle  of  in- 
clination. It  may  be  readily  seen  that  if  the  back  part  of  the 
pelvis  is  elevated  or  the  front  part  lowered,  the  angle  of  inclination 
is  increased;  if  the  back  part  is  lowered  or  the  pubes  elevated,  the 
angle  of  inclination  is  diminished.  That  part  of  the  line  which 
extends  from  the  lumbosacral  angle  to  the  symphysis  pubis  is 
called  the  conjugate  vera  or  internal  conjugate  diameter  and  its 
measurement  is  important  when  consideration  of  the  pelvic  inlet 
as  a  whole  is  to  be  determined  in  the  study  of  the  case  of  the  ex- 
pectant mother. 

Other  measurements  taken  by  obstetricians  are:  (a)  between 
the  iliac  crests;  (b)  between  the  anterior  superior  spines;  (c)  be- 
tween the  posterior  superior  spines;  (d)  between  the  tuber  ischii; 
(e)  between  the  iliac  crests;  (f)  between  the  tip  of  the  coccyx  and 
the  under  edge  of  the  symphysis.  When  a  comparison  is  made 
between  the  figures  given  in  any  authoritative  medical  text  upon 
the  subject  of  obstetrics,  with  the  figures  which  are  suggested  in 
this  book  in  reference  to  changes  wrought  in  sacral  flexion  and 
sacral  extension,  the  deduction  is  logically  made  that  the  cause 
of  the  difference  lies  in  the  relation  of  the  sacrum  to  the  two  in- 
norninates.  Researches  have  been  undertaken  by  some  of  the 
cleverest  investigators  of  the  other  schools  of  practice,  among 
whom  may  be  mentioned  Prochovnik,1  Henggeler,2  Engelhard,3 
Robert  W.  Lovett,4  Joel  Goldthwait,5  but  not  one  of  them  has 

1.  "Archib.  f.  Gyn."  1882,  xix,  I.  2.  "Zeitsch,  f.  orth.  Chir.",  xn,  4, 
613.  3.  "Zeitsch.  f.  ortho.  Chir."  xxvu.  p.  1,  1910.  4.  'Ibidem,  p.  17-19. 

5.  Bos.  Med.  and  Surg.  Jour.,  June  17,  1915.  He  recognizes  "strain" 
of  the  sacro-iliac  joint  but  not  subluxation  in  the  sense  of  immobilization  or, 
as  osteopathists  term  it,  lesion. 


160  OSTEOPATHIC  MECHANICS 

been  able  to  understand  the  fundamental  reason  for  the  differences. 
Lovett  very  honestly  states  that  the  whole  subject  of  pelvic  in- 
clination must  be  left  in  an  unsatisfactory  and  unsettled  condition1 
and  it  is  by  reason  of  the  failure  of  all  investigators  to  recognize 
the  bilateral  sacro-iliac  lesion. 

A  review  of  the  findings2  in  sacral  lesion  may  be  stated  in 
the  terms  of  obstetric  measurements,  thus: 

A.  In  sacral  flexion  lesions,  the  angle  of  pelvic  inclination  is 
greater  and  the  distance  between  the 

1.  Sacral   promontory   and   symphysis   or   the   conjugate 
vera  is  decreased. 

2.  Anterior  superior  spines  less. 

3.  Posterior  superior  spines  less. 

4.  Coccyx  and  under  edge  of  symphysis  pubis  greater. 

5.  Tuber  ischii  greater. 

B.  In  sacral  extension  lesions,  the  angle  of  pelvic  inclination 
is  less  and  the  distance  between  the 

1.  Sacral  promontory  and  the  symphysis  pubis  is  greater. 

2.  Anterior  superior  spines  greater. 

3.  Posterior  superior  spines  greater. 

4.  Coccyx  and  under  edge  of  the  symphysis  pubis  less. 

5.  Tuber  ischii  less. 

Sacral  flexion  lesions  are  followed  by  lordosis  of  the  lumbar 
area,  kyphosis  of  the  dorsal  area,  and  round  shoulders.  The 
degree  of  lesion  varies,  therefore  the  sequelae  vary,  but  the  main 
difference  between  the  normal  pelvis  and  that  having  the  sacral 
flexion  lesion  may  be  found  in  the  presence  of  the  signs  stated 
above. 

Sacral  extension  lesions  are  followed  by  the  straight  spine  and 
the  flat  chest  when  the  lesion  is  extreme.  That  great  variance 
exists  in  the  degrees  of  lesion  may  be  readily  perceived  when  we 
remember  that  Prochovnik  states  that  he  found  the  average  of  his 
collected  results  showed  the  variation  in  males  in  pelvic  inclination 
to  be  from  44  to  60  degrees,  in  women  from  41  to  65  degrees.  The 
pertinent  question  is,  who  has  normal3  sacro-iliac  articulations? 

1.  His  own  words,  loc.  cit. 

2.  Pages  131  and  134. 

3.  It  is  the  author's  opinion  that  at   the  present  time  only  palpation  of 
the  most  skilled  physician  can  determine  the  answer. 


OSTEOPATHIC  MECHANICS  161 

CHAPTER  VIII 
RIB  LESIONS 

A  rib  lesion  is  a  subluxation  or  an  immobilization  of  a  rib  in 
a  position  of  normal  respiratory  movement.  It  usually  results 
from  an  incomplete  inspiration  or  expiration.  Occasionally  it 
may  be  due  to  a  restriction  which  holds  the  rib  from  taking  part 
in  normal  movements.  As  the  result  of  direct  violence,  fracture, 
not  subluxation,  is  produced.  Rare  instances  of  dislocations  of 
the  first  and  twelfth  ribs  have  been  reported  but  with  these  we  are 
not  concerned. 

A  true  rib  lesion  is  independent  of  any  spinal  lesion;  it  is 
present  on  one  side  of  a  vertebra  only,  and  it  must  not  be  con- 
founded with  the  changed  positions  of  the  ribs  attached  to  a  verte- 
bra that  has  become  immobilized  in  lesion.  A  rib  in  articulation 
with  a  lesioned  vertebra  is  not  itself  immobilized ;  its  range  of  move- 
ment may  be  less  than  the  normal;  it  may  show  a  slight  elevation 
at  the  angle  and  a  depression  at  the  chondral  extremity,  or  the 
reverse,  but  differential  diagnosis  will  reveal  the  presence  of  a 
lesion  of  the  vertebra  with  which  it  articulates  doubly  and  treat- 
ment will  be  directed  toward  the  correction  of  the  spinal  lesion, 
frequently  with  the  assistance  of  rib  leverage. 

For  mechanical  purposes,  the  ribs  may  be  divided  into  four 
classes : 

1.  The  first  rib. 

2.  The  ribs  from  the  second  to  the  sixth  inclusive. 

3.  The  seventh,  eight,  ninth,  and  tenth  ribs. 

4.  The  eleventh  and  twelfth  ribs. 

The  ribs  of  the  first  three  classes  have  two  articulations  with 
the  vertebrae  corresponding  in  number;  each  of  the  second  and 
third  classes  of  ribs  articulates  also  with  the  vertebra  above;  the 
first  rib  sometimes  articulates  with  the  body  of  the  seventh  cer- 
vical; the  eleventh  and  twelfth  ribs  articulate  with  the  bodies  only 
of  the  corresponding  thoracic  vertebras  and  are  properly  called 
"floating  ribs." 


OSTEOPATHIC  MECHANICS 


3- 

4- 
\5-"T'os\ex  vo^ 


Rib 


FIGS.    64   AND  65  —  Drawings   to  illustrate    the  connection  of   a  rib  with  the  vertebrae. 
Additional  figures:  V.B.,  body  of  vertebrae;  S.P.,  spinous  process. 


OSTEOPATHIC  MECHANICS 


163 


a  — 


€=: 


—4 


IL 


a-t 


4X13    oif   to 


aA'x 


a  \v. 


FIG.  66 — Drawings  to  illustrate  the  movements  of  the  ribs  in  respiration:  (I)  upon  a  sterno- 
vertebral  axis  and  (II)  upon  a  costotransverse  axis,  the  first  axis  being  that  which  characterizes 
movement  of  the  seventh  to  tenth  ribs  inclusive,  only;  the  second  axis  being  that  of  the  second 
to  the  tenth  ribs  inclusive. 

The  articulations  of  a  typical  rib,  for  an  example  the  right 
third  rib,  are : 

1.  A  costocentral  joint,  formed  by  the  head  of  the  third  rib 
and  the  cavities  on  the  contiguous  surfaces  of  the  second  and  third 
thoracic   vertebral  bodies  and  the  intervertebral  disc  between 
them.     Its  character  is  that  of  an  arthrodial  joint. 

2.  A  costotransverse  joint  formed  by  the  articular  surfaces  on 
the  tubercle  of  the  rib  and  the  adjacent  transverse  process.     It  is 
also  arthrodial  in  type. 

3.  Anteriorly  through  its  cartilage,  with  which  it  is  almost 
inseparably  united,  it  forms  with  the  sternum  a  ginglymus  joint. 

The  axis  of  its  motion1  corresponds  with  a  line  drawn  through 
the  two  articulations  with  the  vertebra,  by  means  of  which  the 
rib,  as  it  rotates  slightly  downward  posteriorly  and  glides  as  in 
an  arc  on  the  transverse  process  of  the  vertebra,  turns  upward  in 
front  and  moves  forward  as  though  to  thrust  the  sternum  anter- 
ior. This  is  the  movement  of  the  second  class  of  ribs  in  inspira- 
tion and  may  be  the  first  part  of  the  inspiratory  movement  of  the 
third  division  of  ribs. 


1.  See:  Cunningham,  ibid,  p.  317,  paragraph  6. 

Gray,  ibid.,  p.  285,  under  heading  "Movements." 


164  OSTEOPATHIC  MECHANICS 

In  expiration,  the  antero-posterior  diameter  of  the  thorax 
decreases,  the  rib  glides  upward  at  its  costotransverse  articulation, 
rotates  upward  at  its  costocentral  joint,  and  is  depressed  anter- 
iorly. Forced  respiratory  movements  will  with  the  aid  of  careful 
palpation  prove  these  movements  of  the  ribs. 

An  inspiration  lesion1  of  one  of  the  second  division  of  ribs 
is  a  subluxation  or  immobilization  of  that  rib  in  the  position  of 
forced  inspiration;  it  is  elevated  at  its  anterior  extremity  and  de- 
pressed at  its  angle. 

The  diagnosis  of  such  a  lesion  is  established  by  the  presence 
of  the  following  invariable  signs: 

1.  Immobility  of  the  rib  in  respiratory  movement. 

2.  Elevation  of  the  anterior  or  chondral  extremity  of  the  rib 
with  some  eversion  of  the  lower  border  of  its  shaft. 

3.  Depression  of  the  angle  of  the  rib,   with   approximation 
to  the  one  below. 

Patients  who  have  rib  lesions  usually  complain  of  a  pain 
located  between  two  ribs,  in  the  anterior  axillary  line,  close  to  the 
angle  of  the  rib,  or  nearer  to  the  spine  in  the  region  of  the  trans- 
verse process.  The  pain  is  a  localized  one,  sharp  in  character, 
nearly  always  constantly  present,  and  mitigated  only  by  applica- 
tion of  counter-irritants.  Careful  physical  diagnosis  can  reveal 
no  organic  cause  for  the  pain.  It  remains  for  its  etiology  to  be 
established  by  finding  a  rib  lesion  present. 

Examination  should  be  made  of  the  whole  outer  surface  of 
the  rib  from  its  junction  with  the  transverse  process  to  its  chondral 
articulation.  This  shaU  be  done  by  palpation,  if  possible  upon 
the  skin;  if  not,  because  of  the  exposure  of  the  person,  through  a 
very  thin,  soft  texture.  Palpation  must  be  carefully  made,  with 
warm  hands,  with  light  pressure,  and  by  varying  the  position  of 
the  patient  and  the  shoulder  girdle.  The  vertebrae  in  articulation 
with  the  rib  should  be  examined  first  of  all  for  lesions.  It  is  pos- 
sible, however,  for  a  rib  lesion  and  a  vertebral  lesion  to  be  present 
at  one  and  the  same  time. 

The  relation  of  the  rib  in  question  to  the  one  above  and  the 
one  below  should  be  noted  throughout  its  length.  With  the  palm 

1.  This  lesion  has  been  called  in  osteopathic  literature  "a  rib  that  is  down 
in  the  back  and  up  in  front." 


OSTEOPATHIC  MECHANICS  165 

of  the  hand  laid  against  the  rib,  with  the  fingers  resting  between 
its  borders  and  those  of  the  adjoining  ribs,  the  patient  should  be 
asked  to  take  a  full  inspiration  and  then  give  a  complete  expiration. 
By  this  test  for  motion,  it  may  be  determined  whether  or  not  a 
lesion  exists.  The  physician  may  stand  behind  the  patient,  who 
is  spare  enough  to  show  the  ribs  in  respiratory  movements,  clasp 
his  hands  in  front  below  the  patient's  sixth  ribs  and  compress 
firmly  his  chest  wall  so  that  he  shall  limit  movement  to  the  upper 
ribs.  If  lesion  is  present,  the  physician  will  note,  by  scanning  the 
anterior  chest  wall,  whether  or  not  there  is  any  failure  of  a  rib  to 
take  part  in  the  movement.  If  all  rise  equally,  lesion  is  not  pres- 
ent and  the  symptoms  are  probably  due  to  a  vertebral  lesion. 

CORRECTIVE  MOVEMENTS 

THE  PRINCIPLE  OF  CORRECTION  FOR  AN  INSPIRATION  RIB  LES- 
ION IS  UPWARD  AND  BACKWARD  ROTATION  AT  THE  VERTEBRAL 
EXTREMITY  OF  THE  RIB. 

GENERAL  RULES. — SINCE  THE  RIBS  HAVE  SOME  ELASTICITY 
IN  THEIR  STRUCTURE,  COMPRESSION  OF  THE  EXTREMITIES  OF  THE 
RIBS  MAY  BE  USED  IN  ASSISTING  TO  ADJUST  THEM.  DlSENGAGE- 
MENT  OF  THE  COSTOTRANSVERSE  ARTICULATION  MAY  BE  OBTAINED 
IN  THIS  WAY. 

When  .one  takes  into  consideration  the  small  axis  of  motion 
upon  which  the  rib  turns,  it  may  be  easily  seen  that  no  adjustment 
can  be  successful  that  is  coarse  and  large.  The  range  of  movement 
in  each  of  the  joints,  the  costotransverse  and  costocentral,  is  lim- 
ited. Although  anteriorly  the  separation  between  the  chondral 
extremity  and  that  of  the  rib  below  seems  very  noticeable,  it  is 
due  to  the  fact  that  the  cartilaginous  articulation  is  at  the  end  of 
the  radius  while  the  angle  is  near  the  centre  of  motion,  the  costo- 
central joint,  and  the  difference  in  the  amount  of  movement  of 
these  two  must  necessarily  be  great. 

No  treatment  need  cause  pain.  The  confidence  of  the  patient 
is  most  easily  shaken  by  rough  technique.1  The  points  of  attack 

1 .  Great  deftness  is  required  in  the  correction  of  these  lesions.  The  tis- 
sues about  the  ribs,  especially  the  mammary  glands,  may  be  seriously  injured 
by  rough  work,  and  no  physician  should  be  excused  who  attempts  a  coarse, 
heavy  movement  for  the  adjustment  of  an  articulation  as  small  in  extent  of 
its  articulating  surfaces  as  the  costotransverse. 


166  OSTEOPATHIC  MECHANICS 

of  avail  are  the  angle  and  the  anterior  extremity  of  the  rib.  Re- 
spiratory movement  may  assist;  inspiration  lesions  will  best  be 
adjusted  at  the  conclusion  of  or  during  expiration  when  there  is 
relaxation  of  the  muscles  that  assist  in  elevating  the  thorax. 

I.  PRONE  ANGLE  MOVEMENT. — The  patient,  B,  is  assumed  to 
have  an  inspiration  lesion  of  the  right  third  rib.     He  is  asked  to 
lie  prone  with  his  arms  hanging  over  the  end  of  the  table.     O  stands 
to  his  left  and  places  the  left  hand  underneath  B,  down  over  his 
chest  until  he  rests  the  palmer  surfaces  of  the  middle  and  index 
fingers  against  the  upper  border  of  the  lesioned   rib.     The  heel 
of  O's  right  hand  is  placed  under  the  angle  of  the  rib  behind  or  he 
may  use  here  the  palmar  surface  of  his  right  thumb  or  his  elbow, 
as  is  most  suitable  to  him.     B  is  asked  to  make  the  cycle  of  a  full 
inspiration  and  then  an  expiration,  and  at  the  close  of  expiration 
O  puts  a  sudden  firm  pressure  against  the  angle  of  the  rib  to  raise 
it  upward,  and  against  the  other  extremity  to  carry  it  downward, 
which,  if  the  tension  is  just  right,  will  result  in  correction. 

This  movement  will  adjust  any  rib  in  inspiration  lesion  from 
the  second  to  the  ninth.  It  may  be  varied  by  having  the  patient 
lie  upon  the  back,  O  standing  to  B's  left  and  reaching  between  the 
shoulders  to  pull  with  the  finger-tips  the  angle  upward  while 
with  the  heel  of  the  hand  the  rib  is  pushed  downward  anteriorly. 

II.  A.  T.  S.  CHAIR  MOVEMENT. — Let  B,  the  patient,  be  as- 
sumed to  have  an  inspiration  lesion  of  the  right  sixth  rib.     He  is 
asked  to  sit  upon  a  chair  that  has  a  high  straight  back  or  upon  a 
chair  especially  arranged  for  the  correction  of  rib  lesions1,  with 
his  left  side  against  the  back  of  the  chair,  to  support  and  immobilize 
the  left  side  of  the  thorax  so  that  no  movement  made  for  correction 
of  the  lesion  will  cause  any  movement  in  the  other  side.    O  stands  to 
the  right  of  B  and  raising  B's  right  arm  places  it  over  his  shoulder. 

O  places  the  thumb  of  his  left  hand  under  the  angle  of  B's 
sixth  rib,  the  fingers  of  his  right  hand  over  the  same  rib  anteriorly. 
During  one  of  B's  expirations,  0  raises  the  angle  of  the  rib  pos- 
teriorly, pushes  it  down  anteriorly,  to  adjust  the  lesion.  It  may 
require  compression  of  the  extremities  of  the  rib  to  disengage  the 
costotransverse  articulation  before  adjustment  can  be  successfully 
accomplished. 

This  movement  will  correct  an  inspiration  lesion  of  any 
rib  from  the  fourth  to  the  ninth. 


1.  Dr.  A.  T.  Still  has  devised  a  chair  for  this  express  purpose.  It  has 
an  upright  curved  piece  of  galvanized  iron  supported  by  two  rods,  which  with 
a  pillow  under  the  axilla  of  the  patient  makes  an  excellent  support. 


OSTEOPATHIC  MECHANICS 


167 


III.  ELBOW  COMPRESSION  MOVEMENT.I — Let  B,  the  patient, 
be  assumed  to  have  an  inspiration  lesion  of  the  right  fifth  rib.  B 
is  asked  to  lie  supine  upon  the  table  without  a  pillow  to  support 
his  head.  0  places  the  fingers  of  his  left  hand  under  the  scapula 
until  they  reach  the  angle  of  the  rib  which  is  down.  They  grasp 
this  angle  with  the  purpose  of  raising  it;  or,  if  O  prefers, "he  can 
place  a  knuckle  under  the  angle  of  the  rib  to  offer  pressure  and  re- 
sistance at  the  moment  of  correction. 


FIG.  67 — Illustrating  the  elbow  compression  movement  for  the  correction  of  an  inspira- 
tion lesion  of  the  left  fourth  rib. 

0  then  grasps  B's  right  elbow  and  moves  it  transversely  across 
his  chest  so  that  it  lies  over  the  anterior  extremity  of  the  rib  in 
lesion.  With  his  hand  upon  the  right  elbow,  O  tries  the  range  of 
movement  that  is  required  to  bring  a  pull  through  the  muscles 
upon  the  fifth  rib  and  also  to  test  the  point  at  which  compression2 

1.  The  author  has  observed  that  osteopaths  differ  in  what  they  consider 
the  best  position  of  the  patient  for  the  adjustment  of  rib  lesions.     Dr.  Still 
and  his  sons  seem  to  prefer  to  have  the  patient  seated  upon  a  stool;  Dr.  Frank 
Farmer  with  them  seated  upon  the  side  of  a  table  in  front  of  him;  Dr.  H.  W. 
Forbes,  the  patient  lying  prone  or  supine  upon  the  table,  working  usually  upon 
the  posterior  extremity  of  the  rib. 

2.  No  extremely  forcible  compression  should  be  used  to  assist  in  correct- 
ing rib  lesions  for  in  many  people  ribs  are  brittle  and  may  fracture  easily, 
especially  is  this  true  of  the  ribs  from  the  sixth  to  the  eighth.     Rib  lesions  are 
not  as  frequently  found  as  was  formerly  supposed  and  when  found  care  should 
be  used  in  the  choice  of  osteopathic  operative  measures. 


168  OSTEOPATHIC  MECHANICS 

is  most  successful  in  moving  the  rib.  With  his  two  hands  working 
in  conjunction  O  may  easily  adjust  the  lesion. 

This  movement  will  adjust  any  inspiration  rib  lesion  from  the 
fourth  to  the  eighth  ribs,  inclusive.  The  above  movements  may 
be  varied  by  position  according  to  the  habit  of  the  physician  and 
the  weight  of  the  patient.  Inspiration  lesions  are  less  common 
than  those  of  the  other  classes  and  types. 

An  expiration  lesion1  is  one  in  which  any  rib  from  the 
second  to  the  tenth  inclusive  is  maintained  in  a  position  of  forced 
or  exaggerated  expiration;  it  is  depressed  at  its  anterior  extremity 
and  elevated  at  its  angle.  Its  diagnosis  is  established  by  the 
presence  of  the  following  signs: 

1.  Immobility  of  the  rib  in  respiratory  movement. 

2.  Depression  of  the  chondral  extremity  of  the  rib  with  some 
eversion  of  its  upper  border  and  with  approximation  to  the  rib 
below. 

3.  Elevation  of  the  angle  of  the  rib  posteriorly  with  promi- 
nence of  its  lower  border  and  separation  from  the  angle  of  the  rib 
below. 

The  expiration  lesion  is  the  commonest  of  the  rib  lesions.  It 
is  usually  the  result  of  accident  by  compression  at  a  moment  of 
forcible  inspiration  or  by  sharp  changes2  in  the  respiratory  cycle 
not  calling  into  use  the  entire  thoracic  capacity.  The  expiration 
lesion  is  not  difficult  of  adjustment  for  its  angle,  prominent  often 
in  the  plane  of  the  back  and  always  to  touch,  offers  an  excellent 
point  of  attack. 

CORRECTIVE  MOVEMENTS 

THE  PRINCIPLE  OF  CORRECTION  FOR  AN  EXPIRATION  LESION 
IS  DOWNWARD  AND  BACKWARD  ROTATION  AT  THE  VERTEBRAL  EX- 
TREMITY OF  THE  RIB. 


1.  This  lesion  has  been  called  "a  rib  up  in  the  back  and  down  in  front." 

2.  As  an  example  of  this  class  of  cases  one  may  be  cited  in  point:  a  young 
woman  in  playing  tennis  jumped  to  strike  a  ball  and  missed  it.     Her  arm  had 
gathered  momentum  carrying  it  beyond  voluntary  control  and  her  racket, 
struck  her  ankle.     The  cycle  of   respiratory  events  was  first  a  sudden  expira- 
tion instantaneously  following  the  missed  stroke.     Then  a  sharp  inspiratory 
movement  in  an  effort  to  regain  control  of  the  arm,  synchronously  with  which 
she  was  seized  with  a  stinging  pain  somewhere  among  the  ribs  under  her  arm. 
It  was  due  to  a  failure  on  the  part  of  the  seventh  rib  to  take  part  in  the  sudden 
movement  of  inspiration.     Examination  years  afterward  for  the  cause  of  the 
pain  which  had  never  ceased,  revealed  an  expiration  lesion  of  the  right  seventh 
rib.     (Patient  examined  in  consultation  with  Dr.  Wm.  Gardner  of  Rockford, 
111.) 


OSTEOPATHIC  MECHANICS  169 

GENERAL  RULE. — EXPIRATION  LESIONS  MAY  BE  CORRECTED 
BEST  AT  THE  MOMENT  OF  FULL  INSPIRATION. 

IV.  HYPEREXTENSION  MOVEMENT. — Let  the  patient,  B,  who 
is  assumed  to  have  an  expiration  lesion  of  the  left  fifth  rib,  be  asked 
to  sit  upon  the  side  of  a  table  and  well  back  so  that  he  may  rest 
his  right  shoulder  against  O's  right  shoulder.     0  reaches  around 
B  with  his  right  arm  until  the  fingers  of  the  right  hand  grasp  the 
fifth  rib  anteriorly  to  lift  it.     O's  left  thumb,  or  the  heel  of  the 
hand,  is  placed  against  the  angle  of  the  fifth  rib  to  thrust  it  down- 
ward when  at  the  conclusion  of  a  full  inspiration  B  seems  to  be 
relaxed. 

V.  PRONE  EXTENSION  MOVEMENT. — Let  the  patient,  B,  hav- 
ing an  expiration  lesion  of  the  right  fifth  rib,  is  asked  to  lie  prone 
upon  the  table.     O  stands  at  the  left  of  B.     O  lifts  B's  body  in 
some  extension,  usually  by  placing  his  flexed  knee  under  B's  chest. 
O  reaches  under  B  to  reenforce  the  upward  pressure  against  the 
anterior  end  of  the  fifth  rib,  while  with  the  heel  of  his  other  hand 
as  close  to  the  vertebral  articulation  with  the  rib  as  it  is  possible 
to  get,  he  exerts  a  gentle  thrust  forward  for  the  purpose  of  disen- 
gaging the  costotransverse  articulation.     O  then  grasps  the  lower 
border  of  the  rib  anteriorly  to  pull  it  up  and  turns  the  heel  of  the 
hand  so  that  he  may  exert  a  strong  pressure  against  the  angle,  in  a 
direction  forward  and  downward  toward  B's  feet.     At  the  limit 
of  inspiration,  the  two  pressures  are  made  synchronously  with 
correction  of  the  lesion. 

VI.  ARM   ASSISTING   MOVEMENT. — Let  the  patient,   B,   lie 
upon  his  left  side  with  the  lesioned  sixth  rib  uppermost.     O  stands 
in  front  of  B  and  an  assistant,  C,  stands  behind  B  and  grasps  the 
elbow  of  B's  right  arm  to  carry  it  upward  according  to  O's  instruc- 
tions.    0  places  the  heel  of  his  left  hand1  strongly  against  the  angle 
of  the  right  sixth  rib.     O's  right  fingers  reach  under  the  lower 
border  of  the  anterior  end  of  the  rib  to  pull  it  up.     B  is  asked  to 
take  a  full  inspiration  and  just  at  the  point  of  beginning  expira- 
tion C  is  told  to  carry  B's  right  elbow  upward,  outward  and  back- 
ward while  O  gives  a  slight  thrust  against  the  angle  of  the  rib  guid- 
ing it  into  place  by  the  fingers  anteriorly. 

VII.  HOOP-ROLLING  RIB  MOVEMENT. — Let  the  patient,  B, 
who  is  assumed  to  have  an  expiration  lesion  of  the  right  eighth 
rib,  lie  upon  the  right  side.     0  standing  in  front  of  B  holds  the 

1.  There  has  been  a  habit  with  a  number  of  osteopathic  physicians  of 
using  the  knee  to  hold  the  vertebral  extremity  of  the  rib  fixed.  In  the  em- 
ployment of  one  who  possesses  rare  skill,  such  a  force  might  be  permissible 
but  it  is  a  method  more  noted  for  its  abuse  than  for  its  safe  use.  No  student 
should  employ  it  in  early  days  of  practice. 


170  OSTEOPATHIC  MECHANICS 

lower  border  of  the  eighth  rib  anteriorly  with  the  fingers  of  the 
left  hand.  B  is  asked  to  put  the  right  limb  behind  the  left.  O  rests 
his  right  elbow  on  B's  left  hip,  the  fingers  of  his  left  hand  pulling 
down  firmly  on  the  angle  of  the  lesioned  rib.  O's  left  shoulder 
rests  against  B's  left  shoulder  anteriorly  and  O  rolls  B  backward 
slightly  as  at  the  close  of  an  inspiration  he  adjusts  the  lesion. 

This  movement  may  be  used  for  the  correction  of  an  expira- 
tion lesion  of  any  of  the  third  division  of  ribs.  Other  movements, 
with  the  patient  seated  on  a  chair  as  in  movement  II,  or  with  the 
patient  lying  supine,  may  be  quite  easily  planned  and  executed, 
having  the  principle  of  correction  constantly  as  a  foundation. 

In  expiration  lesions  of  the  second  rib  assistance  may  be 
given  by  muscular  leverage. 

VIII.  PECTORALIS  MOVEMENT. — Let  the  patient,  B,  who  has 
an  expiration  lesion  of  the  right  second  rib,  sit  upon  a  high  stool 
while  O  stands  beside  him  on  his  right.  O  places  his  left  shoulder 
under  B's  right  axilla  with  the  purpose  of  moving  it  backward  at 
the  right  moment.  O  places  his  right  thumb  under  the  lower 
border  of  the  second  rib  anteriorly,  his  left  thumb  or  index  finger 
knuckle  against  the  angle  of  the  rib  posteriorly.  B  is  asked  to 
take  a  full  breath,  at  the  conclusion  of  which  O  deftly  combines 
the  two  pressures  with  the  lifting  of  the  shoulder  and  adjusts  the 
lesion. 

The  same  movement  may  be  given  with  the  patient  lying 
supine  without  a  pillow.  O  rests  B's  arm  on  his  own  forearm,  his 
hand  being  directed  to  the  downward  movement  of  the  rib  at  its 
angle. 

Inspiration  lesions  of  the  second  rib  may  be  adjusted  with 
the  patient  in  the  same  positions  as  above,  the  arm  of  the  patient 
resting  over  the  shoulder  or  arm  of  the  physician  merely  to  hold 
the  scapular  muscles  relaxed. 

LESIONS   OF  THE  FIRST   RIB 

The  first  rib  differs  in  shape  from  the  other  ribs,  is  controlled 
by  a  different  set  of  muscles  and  does  not  behave  in  inspiration 
and  expiration  like  any  of  the  others.  The  movement  of  the  first 
rib  is  upon  an  antero-posterior  axis.  In  inspiration  the  scaleni 
muscles  contract  and  raise  the  rib,  fixing  it  so  that  the  intercostal 
muscles  below  may  raise  all  of  the  other  ribs  to  increase  the  diam- 
eters of  the  thorax.  The  first  rib  articulates  on  each  side  with 
the  first  thoracic  vertebra  without  an  interarticular  ligament, 


OSTEOPATHIC  MECHANICS  171 

hence  it  may  glide  up  or  down  very  easily  at  that  end.  Anteriorly 
it  is  closely  anchored  to  the  cartilage  which  is  united  with  the 
sternum.  Movement  is  more  pronounced  in  the  posterior  half  of 
the  rib  to  which  the  muscles  are  attached. 

There  are  no  lesions  of  the  first  rib  of  the  true  inspiration  and 
expiration  type.  They  are  rather  called  upward  and  downward 
subluxations.  An  upward  lesion  is  the  result  of  a  sudden  contrac- 
tion of  the  scaleni  muscles  from  a  various  number  of  causes :  first, 
a  protective  contraction  in  an  attempt  to  ward  off  a  blow  directed 
to  the  head ;  secondly,  from  carrying  heavy  weights  on  the  shoulder 
with  the  head  bent  to  one  side  to  get  it  out  of  the  way  and  the 
shoulder  girdle  fixed  in  a  position  of  support  by  the  contraction 
above  mentioned;  thirdly,  from  prolonged  contraction  due  to 
exposure,  cold;  fourthly,  by  falls  upon  the  head  or  shoulders. 
Downward  lesions  of  the  first  rib  are  usually  due  to  a  failure  of  the 
muscles  to  contract  when  a  demand  is  made  upon  them  or  when 
by  fatigue  from  over-exertion  they  lose  their  tone  and  unbalance 
results  with  the  gradual  production  of  lesion.  Depressed  lesions 
of  the  first  rib  are  rare.  Upward  subluxations1  occur  occasionally. 

The  diagnosis  of  a  first  rib  lesion  depends  upon  these  signs : 

1.  Restricted  movement  upon  forcible  inspiration. 

2.  Fullness  or  depression  at  the  side  of  the  neck  where  the 
shaft  of  the  rib  passes  in  front  of  the  trapezius  muscle. 

Differential  diagnosis  must  be  made  from  a  rotation  lesion 
of  either  the  first  or  second  thoracic  vertebra.  A  rotation  lesion 
turns  backward  the  rib  on  the  side  opposite  to  that  toward  which 
the  spinous  process  points.  There  is  a  slight  upward  turning  of 
the  first  rib  but  it  does  not  have  restricted  motion.  Vertebral 
lesions  must  be  corrected  before  adjustment  of  the  rib  lesion  is 
attempted.  The  neck  should  be  examined  for  the  presence  of 
cervical  lesions  which  may  have  been  etiologic  in  the  production 
of  the  rib  lesion,  for  the  scaleni  muscles  are  supplied  by  branches 
from  the  lower  four  or  five  cervical  nerves. 


1.  The  commoner  symptoms  of  which  these  patients  complain  are  pain 
over  the  shoulder,  hacking  cough,  eczema  of  the  hands  and  arms,  bronchitis, 
functional  heart  disturbances,  goitre,  and  congestive  headaches.  When  we 
remember  with  what  important  structures  the  first  rib  is  in  relation,  it  is  not 
to  be  doubted  that  it  proves  the  irritative  source  of  many  symptoms. 


172 


OSTEOPATHIC  MECHANICS 


EXPERIMENTAL  PALPATION,  N.— With  the  subject,  B,  seated 
upon  a  stool  with  O  standing  behind  him,  O  places  perpendicularly 
to  the  anterior  extremities  of  B's  first  ribs  close  to  the  cartilages 
two  matches  on  end.  B  is  asked  to  take  a  full  breath.  If  there  is 
no  lesion  present,  the  matches  will  be  pushed  upward  equally.  If 
one  match  does  not  move,  that  rib  is  in  lesion. 

O  should  carefully  scan  the  relative  height  of  the  two  shoulders 
at  about  the  nape  of  the  neck.  If  one  is  higher  than  the  other, 
he  should  then  push  aside  the  trapezius  upon  that  side  and  palpate 
the  two  first  ribs  to  note  whether  or  not  one  has  greater  obliquity 
than  the  other.  Then  with  his  hands  applied  to  the  upper  surface 
of  the  rib,  B  should  be  asked  to  breathe  ful]y.  The  rib  which  does 
not  respond  to  movement  is  the  one  in  lesion. 

O  may  make  a  further  test  for  motion.  Placing  his  hand  upon 
the  top  of  B's  head  he  may  bend  B's  head  to  the  side  directly  which 
will  lift  the  rib  by  the  direct  pull  on  the  muscle  fibres.  If  the  rib 
does  not  lift  in  this  manner,  lesion  of  the  upward  type  is  present. 

CORRECTIVE  MOVEMENTS 

THE  PRINCIPLE  OF  CORRECTION  FOR  AN  UPWARD  SUBLUXATION 
OF  THE  FIRST  RIB  IS  DOWNWARD  ROTATION  ON  THE  ANTERO- 


Fio.  68 — Schematic  drawing  to  illustrate  the  attachments  of  the  scalenus  anticus  muscle 
and  the  state  of  contraction  of  that  muscle  in  an  upward  subluxation  of  the  right  first  rib. 


OSTEOPATHIC  MECHANICS  173 

POSTERIOR  AXIS  OF  MOTION;  FOR  A  DOWNWARD  SUBLUXATION,  IS 
UPWARD  ROTATION. 

GENERAL  RULES. — SINCE  THE  UPWARD  LESION  HAS  BEEN 
CAUSED  BY  CONTRACTION  OF  THE  SCALENI,  THESE  MUSCLES  MUST 
BE  PLACED  IN  RELAXATION  BY  POSITION  AND  DIRECT  PRESSURE 

USED  FOR  CORRECTION.  IN  DOWNWARD  SUBLUXATION  THE  MUS- 
CLES SHOULD  BE  USED  TO  LIFT  THE  RIB  BY  DIRECT  PULL  ALONG 
THEIR  MUSCLE  FIBRES  WITH  PRESSURE  AGAINST  THE  LOWER  BOR- 
DER OF  THE  POSTERIOR  PART  OF  THE  RIB  TO  ASSIST  IN  RAISING  IT. 

IX.  HALF-ROTATION  MOVEMENT. — Let  the  patient,  B,  who 
is  assumed  to  have  an  upward  lesion  of  the  right  first  rib,  sit  upon  a 
stool,  0  standing  behind  him.     O  places  his  hand  upon  the  top  of 
B's  head,  the  radial  side  of  his  right  index  finger  along  the  posterior 
third  of  the  first  rib  to  push  it  downward  and  slightly  backward  and 
outward  at  the  movement  of  adjustment.     0  bends  B's  head  to 
the  left  and  then  makes  a  quarter  circumduction  to  the  front;  at 
this  point  the  scaleni  of  both  sides  should  be  perfectly  relaxed  and 
it  is  then  that  the  pressure  upon  the  rib  may  adjust  the  lesion. 
If  not,  the  head  may  be  circumducted  ninety  degrees  more  to  the 
right  shoulder,  when  the  right  scaleni  will  be  shortened  as  well  as 
relaxed,  and  adjustment  may  be  made. 

X.  PATIENT  ASSISTING  MOVEMENT. — With  patient  and  physi- 
cian seated  as  above,  instruct  the  patient  to  perform  the  same  move- 
ment with  his  head  that  0  carried  it  through  in  the  half-rotation 
movement.     0  puts  his  right  arm  under  B's  right  axilla  and  raises 
the  shoulder  girdle  in  upward  and  backward  circumduction  to 
exert  a  pull  upon  the  anterior  end  of  the  rib  through  the  subclavius 
muscle  which  takes  origin  from  the  first  rib  and  is  inserted  into 
the  clavicle.     Adjustment  is  made  by  the  pressure  downward  upon 
the  rib  posteriorly  as  above. 

XI.  HEAD  SIDE-BENDING  MOVEMENT. — The  patient,  B,  is 
assumed  to  have  a  depressed  lesion  of  the  right  first  rib.     B  and 
O  have  the  same  relative  positions  as  in  the  above  movements. 
O  places  his  right  thumb  beneath  the  angle  of  the  first  rib  to  pry 
it  up.     0  bends  B's  head  to  the  opposite  shoulder  until  tension 
upon  the  muscle  is  felt,  then  with  an  increase  of  lateral  movement 
the  rib  may  be  raised.     It  should  be  held  immobilized  in  the  normal 
position  while  the  head  is  circumducted  to  the  right  and  through 
several  movements  of  flexion  and  extension  of  the  head  and  neck, 
followed  by  resistance  on  the  part  of  the  patient  when  flexion  is 
attempted  for  the  purpose  of  helping  the  scaleni  to  contract  and 
return  to  their  normal  condition  of  tone. 


174  OSTEOPATHIC  MECHANICS 

Failure  to  adjust  first  rib  lesions  is  due  to  the  fact  that  they 
have  been  in  existence  for  many  years  and  the  contractions  and 
proliferation  of  connective  tissue  about  the  vertebral  articulations 
of  the  rib  are  constrictive  past  the  possibility  of  overcoming  save 
by  a  long  course  of  preliminary  treatment  directed  to  the  estab- 
lishment of  motion  in  the  joints.  If  vertebral  lesions  remain,  it 
is  useless  to  attempt  to  correct  a  rib  lesion.  Removal  of  the 
primary  cause  must  always  be  the  central  thought  in  osteopathic 
procedure. 

LESIONS   OF  THE    THIRD    GROUP   OF   RIBS 

In  addition  to  the  movement  which  is  normal  to  the  second 
group  of  ribs,  the  third  class  has  a  secondary  motion  upon  an 
antero-posterior  axis  with  the  object  of  elevating  the  middle  part 
of  the  rib  thus  increasing  the  transverse  diameter  of  the  thorax. 
When  these  ribs  are  raised  as  in  full  inspiration,  the  lateral  part  is 
thrust  outward  and  from  its  manner  of  action  it  has  been  comT 
pared  to  a  bucket  handle  movement1.  These  lesions  are  prob- 
ably due  to  direct  trauma,  as  by  lateral  interference,2  or  are  se- 
quent upon  vertebral  lesions.  They  are  called  inspiration  and 
expiration  because  the  immobilization  in  each  case  is  in  the  posi- 
tion of  normal  movement. 

An  inspiration  bucket  handle3  lesion  is  one  in  which  any 
rib  from  the  second  to  the  tenth  inclusive  is  so  rotated  on  an  axis 
drawn  from  the  head  of  the  rib  to  the  side  of  the  sternum  that  the 
rib  is  moved  upward  with  its  lower  border  turned  outward  and  its 
outer  surface  upward. 

In  comparing  the  facets  on  the  vertebral  bodies  and  trans- 
verse processes  for  articulation  with  the  heads  and  tubercles  of 
the  ribs,  it  may  be  seen  that  the  facets  for  the  third  group  of  ribs 
are  flat  and  will  permit  of  a  much  wider  range  of  motion.  In 
inspiration,  when  the  axis  is  antero-posterior,  the  two  extremities 

1.  See  Gray,  ibid.,  p.  285,  foot  of  the  page. 

2.  As  for  example  by  leaning  over  a  chair  arm  which  holds  a  rib  from  par- 
ticipation in  normal  thoracic  movement. 

3.  These  lesions  were  named  rotation  rib  lesions  in  the  report  of  the  no- 
menclature committee.     The  author  prefers  to  retain  the  older  name  for  the 
present.     The  definitions  here  given  of  these  lesions  are  those  adopted  by  the 
A.  O.  A.  from  its  committee's  report. 


OSTEOPATHIC  MECHANICS  175 

are  fixed  and  the  rib  rotates  upward  at  its  middle,  gliding  upward 
on  the  transverse  process,  which  sometimes  presents  a  problem  in 
correction  for  if  the  rib  becomes  securely  lodged  there,  it  is  neces- 
sary to  disengage  it  from  that  barrier  first.  This  may  be  done 
as  in  other  lesions  of  the  second  and  third  groups  by  making  use 
of  the  elasticity  of  the  rib  compressing  it  at  its  angle  and  at  its 
anterior  extremity,  when  with  a  slight  impetus1  to  guide  it  in  the 
right  direction  it  may  be  held  until  the  adjustive  movement  is 
given. 

The  diagnosis  of  an  inspiration  bucket  handle  rib  lesion  may 
be  determined  as  follows : 

1.  Restricted  motion. 

2.  Widening  of  the  interspace  between  the  lesioned  rib  and 
the  one  below  in  the  midaxillary  line;  interspaces  at  the  vertebral 
and  sternal  ends  not  deviated  from  the  normal. 

3.  Lower  border  of  the  rib  in  lesion  turned  outward  and  the 
outer  surface  turned  upward. 

CORRECTIVE  MOVEMENTS 

THE  PRINCIPLE  OF  CORRECTION  FOR  AN  INSPIRATION  BUCKET 
HANDLE  LESION  IS  DOWNWARD  ROTATION  IN  THE  MIDAXILLARY 
LINE. 

GENERAL  RULES. — DISENGAGEMENT  OF  THE  UPPER  EDGE  OF 
THE  RIB  FROM  THE  UNDER  BORDER  OF  THE  RIB  BENEATH  MAY  BE 

NECESSARY  PRECEDING  CORRECTION.  IT  MAY  BE  ACCOMPLISHED 
BY  SIDEBENDING  OR  ROTATION  TO  THE  OPPOSITE  SIDE  WITH  PRES- 
SURE APPLIED2  TO  THE  LESIONED  RIB  TO  SEPARATE  IT  AT  THE 
MOMENT  OF  UPWARD  MOVEMENT  OF  THE  RIB  ABOVE. 

XII.  SIDE-PULLING  MOVEMENT. — The  patient,  B,  is  assumed 
to  have  an  inspiration  bucket  handle  lesion  of  the  right  ninth  rib. 
He  is  asked  to  sit  on  a  stool  or  a  low  table  while  0  stands  to  his 
left  and  reaches  around  B  with  both  arms,  applying  the  right 
thumb  as  near  to  the  vertebral  extremity  as  possible,  while  with 
the  left  thumb  pressure  is  put  toward  the  anterior  end  of  the  rib, 
the  middle  finger  of  each  hand  lying  above  the  upper  border  of 
the  shaft  as  far  out  on  the  rib  as  possible.  O  springs  the  rib  enough 
to  know  that  his  leverages  are  right  and  then  pulls  B  sidewise 
toward  him  which  spreads  the  vertebrae  and  ribs  upon  the  left  and 
approximates  them  somewhat  upon  the  right.  B  is  asked  to  take 


1.  This  is  called  springing  the  rib. 

2.  That  is,  by  springing  the  rib. 


176 


OSTEOPATHIC  MECHANICS 


FIG.  69 — Illustrating  a  corrective  movement  for  an  expiration  bucket  handle  lesion  of  the 
I  eft  ninth  rib,  the  interspace  below  the  ninth  represented  by  crosses. 

a  breath  during  the  beginning  of  the  sidewise  movement  and  at 
its  conclusion  to  exhale;  toward  the  close  of  the  expiration  the 
adjustment  is  made. 

An  expiration  bucket  handle  lesion  is  one  in  which  any 
rib  from  the  second  to  the  tenth  inclusive  is  so  rotated  on  an 
axis  from  the  head  of  the  rib  to  the  side  of  the  sternum  that  the 
rib  is  moved  downward  with  its  upper  border  turned  outward 
and  its  outer  surface  downward.1 

CORRECTIVE  MOVEMENTS 

THE  PRINCIPLE  OF  CORRECTION  FOR  AN  EXPIRATION  BUCKET 
HANDLE  LESION  IS  UPWARD  ROTATION  ON  THE  ANTERO-POSTERIOR 
AXIS  OF  MOTION. 


1.  Definition  of  the  committee  on    terminology    before  mentioned  but 
with  the  name  of  rotated  expiration  lesion  instead. 


OSTEOPATHIC  MECHANICS 


177 


GENERAL  RULES. — DISENGAGEMENT  OF  THE  LOWER  BORDER 


HAD  BY  SPRINGING  THE  RIB  AND  BY  ROTATING  THE   PATIENT  STRONG- 
LY TO  THE   SIDE   OPPOSITE  THE   LESION. 

XIII.  SIDE  SPREADING  MOVEMENT. — -The  patient,  B,  is 
assumed  to  have  an  expiration  bucket  handle  lesion  of  the  ninth 
left  rib.  B  is  asked  to  sit  upon  a  stool  or  on  the  end  of  a  low  table, 
O  standing  beside  him  to  the  right.  O  takes  hold  of  the  rib  as  in 
the  last  corrective  movement,  and  after  springing  it  guides  it  up- 
ward at  the  centre  while  pushing  B  sidewise  away  from  0  thus 
lengthening  the  lateral  wall1  of  the  thorax  on  the  side  of  the  lesion 
and  giving  an  added  impulse  to  the  intercostal  muscle  above  the 
lesioned  rib  to  contract. 

LESIONS   OF   THE  FOURTH   GROUP  OF  RIBS 

The  eleventh  and  twelfth  ribs  differ  from  the  others  in  that 
they  are  not  as  much  curved,  do  not  articulate  by  more  than  one 


FIG.  70 — Schematic  drawing  to  illustrate  the  quadratus  lumborum  muscle  and  its  action 
in  connection  with  lesions  of  the  twelfth  rib.  The  dotted  lines  indicate  the  position  of  the  rib 
when  drawn  down  by  this  muscle. 

1.  Producing  a  convexity  is  not  sufficient,  for  it  may  be  seen  that  when 
B  is  sidebent  to  the  right,  a  great  deal  of  the  side  stretching  comes  in  the 
lumbar  area,  affecting  the  eleventh  and  twelfth  ribs  and  not  those  above 
especially. 


178  OSTEOPATHIC  MECHANICS 

joint  with  their  respective  vertebrae,  have  no  tubercles,  and  no 
cartilaginous  connection  with  other  ribs,  the  cartilages  of  these 
terminating  in  the  walls  of  the  abdomen. 

Lesions  are  caused  by  contraction  of  the  quadratus  lumborum 
upon  the  twelfth  rib,  by  the  pull  of  the  lateral  abdominal  muscles, 
by  traumatism,  and,  rarely,  by  forced  respiratory  movements. 

The  lesions1  are  upward  or  downward  rotations.  Normally 
the  inner  surface  of  the  twelfth  rib  faces  slightly  upward.  When 
an  upward  lesion  occurs  the  twelfth  rib  is  raised  at  its  anterior 
extremity  until  often  it  has  passed  beneath  the  border  of  the 
eleventh,  especially  when  the  twelfth  rib  is  unusually  short.  In 
downward  displacements,  the  rib  rotates  slightly  so  that  its  inner 
surface  faces  inward  and  slightly  downward  and  the  anterior  ex- 
tremity of  the  rib  is  much  depressed.  The  last  intercostal  muscle 
in  such  a  case  is  thinned  and  atrophied. 

The  eleventh  is  subject  to  lesions  in  company  with  the  twelfth, 
due  to  the  tenacity  of  the  intercostal  muscle  between  them.  There 
may  be  found  these  lesions  of  the  last  group  of  ribs : 

1.  Eleventh  and  twelfth  ribs  depressed,  a  lesion  in  which  these 
ribs  have  been  immobilized  in  a  position  of  traumatic  strain  down- 
ward, with  a  slight  rotation  on  a  longitudinal  axis  in  the  same  di- 
rection. 

2.  Eleventh  and  twelfth  ribs  raised,  a  lesion  in  which  these 
ribs  have  been  immobilized  in  a  position  of  forced  inspiration  with 
some  rotation  on  a  longitudinal  axis  upward. 

3.  Twelfth  rib  depressed. 

4.  Twelfth  rib  raised. 

The  diagnosis  of  the  depressed  lesion  of  the  twelfth  rib  may 
be  established  by  the  presence  of  the  following  signs : 

1.  Separation  of  the  twelfth  rib  from  the  eleventh  throughout 
its  entire  length  but  more  especially  at  the  costal  extremity. 

2.  Restricted  motion. 

When  the  lesion  is  of  the  eleventh  and  twelfth,  both  depressed, 
the  diagnosis  is  practically  the  same,  restricted  motion  being  the 
sign  of  lesion  and  separation  between  the  upper  border  of  the 
eleventh  and  the  lower  border  of  the  tenth  the  evidence  of  a  de- 
pressed lesion  of  these  ribs. 


1.  The  experiment  described  by  C.  P.  McConnell  (A.  O.  A.  Jour.,  June, 
1911,  pg.  476,  notes  the  effect  of  such  lesions. 


OSTEOPATHIC  MECHANICS  179 

CORRECTIVE  MOVEMENTS 

THE  PRINCIPLE  OF  CORRECTION  FOR  A  DEPRESSED  TWELFTH 
RIB  LESION  IS  UPWARD  RAISING  AND  INWARD  ROTATION  OF  THE 
RIB. 

GENERAL  RULE.  —  THE  QUADRATUS  LUMBORUM  MUSCLE 
MUST  BE  RELAXED  SINCE  ITS  CONTRACTION  IS  ONE  OF  THE  FACTORS 
MAINTAINING  LESION. 

XIV.  QUADRATUS  LUMBORUM  MOVEMENT. — The  patient,  B, 
is  assumed  to  have  a  depressed  lesion  of  the  right  twelfth  rib.  He 
is  asked  to  lie  supine  on  the  table  and  flex  his  knees  resting  the  feet 
on  the  table.  O  stands  beside  the  table  on  B's  left.  He  reaches 
around  B's  knees  and  takes  hold  of  his  legs  so  that  he  can  swing 
them  about,  making  a  concavity  on  the  left  side,  a  convexity  on 
the  right,  stretching  the  quadratus  muscle,  while  he  holds  with  his 
right  hand  the  lesioned  twelfth  rib  as  a  fixed  insertion  against 
which  to  stretch  the  muscle.  Several  leg-sidebendings  may  be 
necessary  for  this  purpose. 

0  then  passes  his  right  hand  under  B's  back  until  the  middle 
finger  presses  against  the  rib  at  its  vertebral  extremity  pushing  it- 
out  into  the  abdominal  wall.  With  his  left  hand  O  grasps  the 
costal  end  and  lower  border  of  the  rib  and  pulls  it  up  to  its  accus- 
tomed place  below  the  eleventh.  Then  holding  the  rib  throughout 


FIG.  71 — Illustrating  the  method  of  -stretching  the  quadratus  lumborum  muscle  when 

n  of  t,hp  twplft.Vi  rih  is  nrnspnt 


. 
lesion  of  the  twelfth  rib  is  present. 


180 


OSTEOPATHIC  MECHANICS 


its  length,  O  leans  his  right  shoulder  against  B's  chest  to  limit  the 
upper  excursion  of  the  thorax  while  B  takes  a  deep  breath.  The 
rib  should  be  held  thus  for  several  moments  while  B  repeats  the 
deep  inhalations. 

XV.  BIAS  ROTATION  MOVEMENT. — Let  B  lie  upon  the  left 
side,  while  O  stands  behind  him  holding  the  twelfth  rib  upward  in 
place,  or  holding  the  eleventh  and  twelfth  when  both  are  de- 
pressed, while  his  right  elbow  in  front  of  B's  right  innominate  and 
his  left  elbow  behind  B's  shoulder,  he  is  able  to  control  a  bias 
stretching  of  the  quadratus  lumborum  and  the  lateral  abdominal 
muscles.     B  is  asked  to  assist  by  cam-ing  his  leg  back  and  by  ro- 
tating his  right  shoulder  forward  at  the  same  time  he  takes  a  deep 
breath.     O  ma.y  reenforce  his  left  hand  with  his  right  if  he  prefers. 

XVI.  SHOULDER-RAISING  MOVEMENT. — Let  the  patient.  B, 
who  is  assumed  to  have  a  depressed  lesion  of  the  right  eleventh  and 


FIG.  72 — Illustrating  a  method  of  raising  all  the  >ibs  when  liver  treatment  is  indieated;or 
a  manner  of  placing  the  patient  for  the  adjustment  of  an  expiration  bucket  handle  lesion,  or 
for  lifting  depressed  eleventh  and  twelfth  ribs. 


OSTEOPATHIC  MECHANICS  181 

twelfth  ribs,  lie  upon  his  left  side.  O  stands  behind  him  and  tak- 
ing hold  of  B's  right  arm  steps  between  it  and  his  chest  wall.  He 
asks  B  to  grasp  his  right  shoulder  so  that  0  may  by  a  backward 
bending  lift  all  the  ribs  upon  B's  right  chest  wall  through  the  pull 
of  the  muscles  attached  to  the  shoulder  girdle.  0  faces  B's  feet 
and  with  his  fingers  under  the  under  borders  of  the  eleventh  and 
twelfth  ribs  pulls  them  up  while  at  the  same  time  by  some  back- 
ward bending  he  raises  all  the  ribs  of  the  right  wall  of  the  thorax. 

CORRECTIVE  MOVEMENTS 

THE  PRINCIPLE  OF  CORRECTION  FOR  AN  ELEVATED  TWELFTH 
RIB  IS  SEPARATION  FROM  THE  ELEVENTH  WITH  OUTWARD  ROTATION. 

GENERAL  RULES. — CONTRACTION  OF  THE  INTERCOSTAL  MUS- 
CLES BETWEEN  THE  ELEVENTH  AND  TWELFTH  RIBS  AND  ATONY 
OF  THE  QUADRATUS  LUMBORUM  MUSCLE  MUST  BE  OVERCOME. 

XVII.  ADHESION-BREAKING  MOVEMENT. — -The  patient,  B, 
is  assumed  to  have  an  upward  lesion  of  the  right  twelfth  rib,  with 
the  costal  extremity  of  that  rib  held  under  the  lower  border  of  the 
eleventh.  With  the  patient  in  the  position  of  the  quadratus  lum- 
borum  movement,  0  reaches  under  B's  back  and  pushes  upward 
against  the  vertebral  extremity  of  the  twelfth  rib,  which  is  usually 
sufficient  to  carry  its  costal  extremity  out  from  under  the  border 
of  the  eleventh.  O  then  grasps  the  end  of  it  to  hold  the  separation 
gained  until  O  may  place  the  tip  of  his  middle  finger  between  the 
eleventh  and  twelfth  ribs  at  the  vertebral  end.  O  then  places 
the  left  middle  finger  behind  the  right  one  pushing  the  right  one 
slightly  ahead.  O  then  withdraws  the  right  hand  and  places  the 
middle  finger  behind  the  finger  of  the  left  hand  and  pushes  that 
finger  by  slow  steady  movements  forward  in  the  effort  to  forcibly 
wedge  the  ribs  apart  and  stretch  the  contracted  intercostal  muscle 
and  break  any  connective  tissue  adhesions  that  may  have  formed. 

Upward  lesions  of  the  eleventh  and  twelfth  together  may  be 
treated  in  much  the  same  way  for  the  two  ribs  have  seemed  to 
move  as  one  upward. 

After  the  intercostal  contractions  have  been  overcome,  O 
may  place  his  right  hand  firmly  against  the  lower  border  of  the 
tenth  rib,  when  the  eleventh  and  twelfth  are  in  lesion,  or  against 
the  lower  border  of  the  eleventh  when  the  twelfth  only  is  in  up- 
ward lesion,  and  using  the  first  part  of  the  quadratus  lumborum 
movement,  O  may  pull  the  ribs  below  the  fixed  point  downward 
and  assist  in  correcting  the  lesion. 


182  OSTEOPATHIC  MECHANICS 

The  shoulder-raising  movement  may  be  used  in  the  same 
way  by  placing  the  hand  underneath  the  lowest  rib  not  in  lesion  and 
by  the  upward  pulling  of  the  lateral  thoracic  wall  stretch  the  inter- 
costal muscle  in  contraction.  O  may  place  his  thumb  close  to  the 
vertebral  border  of  the  rib  between  it  and  the  rib  above  and  grad- 
ually wedge  it  forward  using  shoulder-raising  in  conjunction. 

AFTER-TREATMENT 

The  first  requirement  for  the  maintenance  of  rib  correction  is 
proper  respiratory  action.  Breathing  correctly  done  helps  to 
establish  a  normal  equilibrium  and  also  to  maintain  the  flexibility 
of  the  segments  of  the  thoracic  area  of  the  spine.  Especially 
should  the  physician  inquire  into  the  habitual  sitting  position  of 
the  patient  for  those  of  sedentery  life  are  notoriously  poor  breath- 
ers. Examination  of  the  upper  air  passages  should  be  made  to 
discover  any  obstructions  that  might  impede  respiration. 

The  importance  of  these  lesions  should  need  no  demonstra- 
tion to  those  who  remember  that  the  thoracic  ganglia  lie  on  the 
anterior  surfaces  of  the  heads  of  the  ribs.  The  researches  of  Dr. 
Louisa  Burns  of  "The  A.  T.  Still  Research  Institute"  of  Chicago 
have  confirmed  clinical  evidence  that  the  blood  content  is  changed 
after  the  correction  of  rib  lesions. 

THE  STRAIGHT  SPINE  AND  THE  FLAT   CHEST 

The  patient  who  suffers  from  having  a  straight  spine  and  a 
flat  chest  upon  physical  examination  presents  the  following  clin- 
ical signs:  decreased  pelvic  inclination,  straight  lumbar  area, 
flat  dorsal  region,1  straight  cervical  area;  winged  scapulae;  decreased 
antero-posterior  diameter  of  the  thorax  and  increased  transverse 
diameter  of  the  same;  arms  seemingly  longer  than  the  normal; 
in  men,  prominence  of  the  crico-thyroid  cartilages.  The  symp- 
toms of  which  they  complain  are  lowered  resistance  with  a  tend- 
ency to  catching  cold,  catarrhal  predisposition,  bronchitis,  and 
influenza;  they  are  easily  affected  by  the  stimuli  of  environment, 
barometric  changes,  season,  altitude;  neurasthenia  with  its  con- 
comitant symptoms  of  irritability,  dyspepsia,  vaso-motor  dis- 

1.  This  has  been  spoken  of  as  the  anterior  dorsal  in  our  earlier  literature. 


OSTEOPATHIC  MECHANICS  183 

turbances.  It  seems  impossible  for  them  to  remain  well  long  at  a 
time,  respiration  is  insufficient,  they  suffer  from  malnutrition,  and 
even  though  ambitious  want  the  necessary  energy  to  accomplish 
more  than  the  average  quota  of  achievement.  They  are  subject 
to  nervous  disturbances  in  consequence  of  the  rigidity  which  is 
often  present  in  pelvic  and  spinal  articulations,  resulting  in  con- 
stant jarring1  of  the  highly  sensitive  nervous  tissues. 

The  flat  chest2  is  characterized  by  an  increase  in  obliquity  of 
the  ribs,  of  the  fourth  to  the  seventh  in  particular,  with  narrowed 
interspaces,  sternal  and  vertebral  ends  closer  together  with  in- 
creased curving3  laterally.  The  subcostal  angle  is  less  than  a 
right  angle.  It  is  in  large  measure  due  to  the  change  in  the  shape 
of  the  ribs  that  the  dorsal  spine  becomes  straight.  A  flat  dorsal 
area  upon  close  examination  of  the  spine  of  the  cadaver,  shows 
more  or  less  extension  of  each  of  the  thoracic  vertebral  joints, 
with  subsequent  narrowing  of  intervertebral  foraminse  and  impair- 
ed circulation  to  the  spinal  centres,  which,  in  the  area  of  vaso- 
motor  control,  is  full  of  suggestion  as  to  consequences. 

The  causes  of  this  condition  are  many:  first  may  be  men- 
tioned the  influence  of  heredity  predisposing  to  weakness  and 
insufficient  muscular  strength  to  avoid  the  pitfalls  of  faulty  atti- 
tudes and  habits;  secondly,  infectious  conditions  which  through 
sequent  weakness  predispose  to  the  same  condition,  as  pneu- 
monia, the  exanthemata  in  severe  form,  tuberculosis  and  pleurisy 
in  adults,  and  any  irritative  process  which  may  immobilize  the 
chest  wall  as  herpes  zoster,  fractured  ribs,  pleural  adhesions;  it 
is  directly  caused  by  disturbances  in  equilibrium,  as  accompanying 
extension  lesions  of  the  sacrum4,  injuries  to  the  cervical  or  upper 
dorsal  regions,  or  resultant  upon  extreme  weakness  in  children 
who  are  sent  to  school  and  told  to  stand  erect  with  shoulders  back, 
a  pernicious  order  aggravating  the  real  condition  instead  of  ame- 
liorating it.  Obstructive  hindrances  to  breathing,  such  as  ade- 
noids, nasal  polypi,  enlarged  turbinates,  predispose  to  lessened 


1.  See  page  135,  paragraph  1. 

2.  The  flat  chest  has  been  designated  in  the  older  medical  literature  as 
the  paralytic,  phthisinoid,  and  phthisical  chest. 

3.  The  shape  of  the  ribs  actually  changes,  the  curve  is  more  pronounced 
and  the  obliquity  greater. 

4.  See  pg.  135,  paragraph  2. 


184  OSTEOPATHIC  MECHANICS 

respiration,  secondarily  poor  habits  of  breathing  and  impaired 
capacity  of  the  lungs,  after  which  naturally  follows  a  diminution 
in  the  diameters  of  the  chest. 

The  diagnosis  rests  upon  the  presence  of  the  signs  and  symp- 
toms above  described. 

CORRECTIVE  MOVEMENTS 

THE  PRINCIPLES  OF  CORRECTION  FOR  A  STRAIGHT  SPINE  AND  A 
FLAT  CHEST  ARE  RESTORATION  OF  EACH  SPINAL  AREA  TO  ITS  NORMAL 
PHYSIOLOGICAL  CURVE;  OF  EACH  \ERTEBRAL,  RIB,  AND  SACRO- 
ILIAC  ARTICULATION  TO  ITS  NORMAL  MOTION;  OF  EACH  RIB  TO  ITS 
NORMAL  FORM  AND  POSITION. 

GENERAL  RULES. — THE  AREAS  OF  THE  SPINE  SHALL  BE  CON- 
SIDERED AS  SEPARATE  GROUP  LESIONS  WITH  TREATMENT  DIRECTED 
IN  ACCORD  WITH  THAT  IDEA.  EACH  DORSAL  SEGMENT  SHALL  BE 
TREATED  IN  TURN.  THE  SACRUM  SHALL  BE  REGARDED  AS  AN 
EXTENSION  SACRAL  LESION  AND  SHALL  BE  ADJUSTED  BY  FLEXION 
OF  THE  SACRUM  OR  EXTENSION  OF  BOTH  INNOMINATES.  THE  BEND 
SHALL  BE  REDUCED  IN  EACH  RIB  BY  A  COMBINATION  OF  COMPRESSION 
AND  STIMULATION  OF  NORMAL  EXPANSION;  BY  THE  LATTER  MEANS 
THE  RIB  WILL  BE  RAISED  TO  ITS  NORMAL  POSITION,  FOR  A  RIB  PRE- 
VENTED FROM  EXPANDING  IN  ONE  DIRECTION  WILL  EXPAND  IN 
ANOTHER. 

The  patient  must  be  examined  thoroughly  for  organic  condi- 
tions which  may  be  predisposing  to  the  continuation  of  the  condi- 
tion. Adenoid  tissue  must  be  removed  when  it  exists  in  the  upper 
air  passages.  Lack  of  proper  hygienic  surroundings  and  occupa- 
tion must  be  remedied.  If  the  patient  is  young  and  frail  the  treat- 
ment must  be  very  carefully  administered  for  with  these  patients 
at  any  age  the  resistance  is  so  much  lowered  that  cure  is  a  slow 
process.  They  should  be  told  frankly  that  there  is  no  easy  road 
to  recovery  and  that  it  will  require  patience  on  the  part  both  of 
physician  and  patient. 

Examination  should  be  made  for  spinal  and  rib  lesions  for 
any  additional  exciting  cause  must  be  removed  before  the  specific 
treatment  can  avail  much.  Between  treatments  the  patient  should 
assume  as  often  as  possible  the  proper  standing  position  with  the 
weight  on  the  balls  of  the  feet,  the  lumbar  area  in  forward  exten- 


OSTEOPATHIC  MECHANICS 


185 


sion.  All  patients  under  thirty  years  of  age,  without  organic 
conditions,  should  be  cured.  Patients  over  thirty  may  be  helped. 
XVIII.  EXPANSION  TRANSVERSE  COMPRESSION  MOVEMENT. 
—Let  the  patient,  B,  lie  upon  the  table  in  the  position  described 
in  experimental  palpation,  F,  page  98.  Let  O  take  the  same 
relative  position  to  B  and,  placing  his  right  arm  under  B's  lateral 
thoracic  wall,  rest  the  right  palm  over  the  ribs  that  lie  just 
below  the  scapula  in  the  posterior  axillary  line,  reenforcing  the 
pressure  with  the  left  hand  over  the  right.  0  then  places  his 
chest  against  the  right  anterior  axillary  line  in  a  direct  diagonal 
line  from  the  hands.  B  then  turns  his  chest  forward  toward  the 
ventral  position  and  is  instructed  to  take  a  full  breath  and  hold  it 
as  long  as  possible.  0  begins  at  the  middle  of  B's  inhalation  to 
exert  pressure  between  his  hands  and  the  chest,  maintaining  the 
pressure  while  B  holds  his  breath  and  then  relaxing  it  rapidly  as 
B  exhales.  While  B  is  holding  his  breath  and  0  is  maintaining  the 


FIG.  73 — Illustrating  the  diagonal  transverse  pressure  to  be  applied  in  the  correction  of 
the  condition  of  flat  chest  and  straight  spine. 


186  OSTEOPATHIC  MECHANICS 

pressure,  O  adds  a  slight  rotation  of  B's  torso  backward,  but  not 
passing  the  direct  lateral  position,  at  which  point  pressure  and 
respiratory  expansion  are  greatest.  This  movement  should  be 
repeated  nine  times  upon  each  side.  The  spine  should  be  bared 
that  O  may  observe  the  effect  upon  the  thoracic  vertebrae. 

The  amount  of  pressure  exerted  should  be  increased  as  the 
patient  continues  treatment,  beginning  with  only  a  few  foot-pounds 
of  pressure  at  first  and  then  as  the  condition  improves  making  use 
of  more  constraint  in  the  diagonal  diameter.  The  caution  to  be 
observed  is  that  pressure  shall  not  be  applied  before  B  has  produc- 
ed quite  a  little  thoracic  expansion  and  that  the  compression  shall 
not  be  unbearable  at  any  time  in  the  treatment  of  the  case.  The 
movements  will  need  to  be  repeated  at  different  levels  if  the  entire 
thorax  is  involved. 

The  same  movement  may  be  given  with  the  patient  sitting  on 
a  stool  leaning  against  the  wall  or  in  the  case  of  a  child  against  the 
table.  O  in  either  case  kneels  to  bring  his  chest  at  a  proper  level 
for  compression. 

The  same  movement  may  be  used  for  the  correction  of  tho- 
racic functional  curvature  by  having  the  patient  lie  upon  the  side 
of  the  convexity  and  giving  the  movement  to  expand  the  chest 
in  the  opposite  diagonal  diameter. 

A  similar  operation  is  made  for  the  assistance  of  a  heart  which 
is  dilated  and  needs  more  room.  It  may  be  described,  thus: 

XIX.  CAPACITY  INCREASING  MOVEMENT. — Let  B,  the  pa- 
tient, who  is  assumed  to  have  a  heart  in  the  state  of  dilatation  or 
uncompensated  hypertrophy  to  whom  some  relief  may  be  given  by 
more  room  on  the  left  side  of  the  thorax,  lie  supine  upon  the  table. 
O  stands  to  his  right  and  places  his  left  hand  underneath  B's  back 
until  the  palmar  surface  of  the  hand  rests  against  the  posterior 
axillary  line  in  the  area  of  the  left  fifth  to  eighth  ribs.  O  reenforces 
the  right  hand  with  the  left  which  is  passed  across  the  abdomen. 
O  places  his  chest  against  the  anterioi  axillary  line  on  the  right 
and  makes  diagonal  transverse  compression  while  B  holds  a  full 
breath,  relaxing  the  pressure  as  B  expires.  It  may  be  necessary 
to  give  B  resting  periods  between  the  corrective  movements  and 
his  position  may  be  varied  to  suit  the  circumstances.  The  prin- 
ciple of  correction  remains  the  same,  the  production  of  functional 
curvature  convex  to  the  right  so  that  diagonally  across  the  thorax 
there  will  be  bulging  anteriorly. 


OSTEOPATHIC  MECHANICS 


187 


CHAPTER  IX 
OCCIPITO-ATLANTAL  LESIONS 

The  articulations  between  the  occiput1  and  atlas  and  between 
the  atlas  and  axis  are  classed  as  diarthroses,  freely  movable  joints. 
The  occipito-atlantal  joints  are  called  condylarthroses  because 
the  articulating  surfaces  are  the  condyles  of  the  occiput  and  the 
superior  facets  of  the  atlas.  There  are  three  arthrodial  joints 
between  the  atlas  and  axis,  two  being  formed  by  articular  facets, 
the  third,  a  trochoid  or  pivot-joint,  formed  by  the  dens  articulating 
with  the  anterior  arch  of  the  atlas  in  front  and  with  the  transverse 
ligament  behind. 

£  Briefly  reviewed,  the  condyles  of  the  occiput  are  oval  in  form, 
convexo-convex  so  that  facing  downward  they  also  face  forward, 
backward,  and  outward.  They  do  not  lie  parallel  to  each  other 
save  in  those  people  of  different  races  who  have  borne  weights 
upon  their  heads.  Almost  always  the  condyles  converge  toward 
each  other  anteriorly  and  diverge  from  each  other  posteriorly. 


FIG.  74 — Drawing  of  the  superior  surface  of  the  normal  atlas  showing  by  dotted  lines  the 
positions  of  the  dens  and  the  transverse  ligament;,  the  convergence  anteriorly  of  the  articular 
facets  should  be  noted. 

1.  In  osteopathic  literature  the  word  occiput  is  used  interchangeably 
with  occipital  bone. 


188  OSTEOPATHIC  MECHANICS 

The  superior  articular  facets  of  the  atlas  correspond  in  shape 
and  relation  to  the  condyles  of  the  occipital  bone.  They  are 
concavo-concave  and  the  posterior  margins  are  on  a  slightly  lower 
level  than  the  anterior  ones.  They  face  upward,  medially,  and 
slightly  forward  and  backward. 

The  movements  of  the  atlas  upon  the  axis  have  been  well 
understood  by  anatomists  for  years  but  of  the  movements  of  the 
occiput  upon  the  atlas  little  is  known  beyond  flexion  and  extension. 
Lateral  bending  has  been  recognized  lately  but  rotation  is  practically 
unknown.1 

FLEXION   OF  THE   OCCIPUT 

Flexion  is  accomplished  in  the  occipito-atlantal  articulation 
by  a  moving  of  the  condyle  backward,  downward,  and  inward 
upon  the  corresponding  facet  of  the  atlas,  explained  in  detail,  thus: 
when  the  top  of  the  head  moves  forward  both  condyles  glide  back- 
ward and  since  they  converge  anteriorly  their  anterior  extremities 
in  moving  backward  must  encroach  upon  the  lateral  masses  of 
the  atlas  internal  to  the  facets,  and  also,  because  the  facets  slope 
downward,  the  condyles  must  glide  downward.  When  they  come 
to  rest,  the  posterior  one-third  of  each  condylar  surface  projects 
beyond  the  posterior  margin  of  each  facet;  the  remaining  part 
of  each  condyle  rests  upon  the  inner  one-half  of  the  posterior  two- 
thirds  of  each  facet.  The  axis  of  motion  is  a  transverse  one 
represented  by  a  line  which  passes  through  the  jugular  processes 
of  the  occipital  bone,  in  the  average  individual. 

1.  It  is  a  strange  fact  but  nevertheless  true  that  syndesmology  has  been 
given  less  of  exhaustive  study  than  any  of  the  other  systems  of  the  human 
body  save  where  a  joint  has  had  surgical  importance.  Even  in  a  text  as 
standard  as  Cunningham's  Anatomy,  seven  pages  will  be  given  to  a  presenta- 
tion of  the  knee-joint  while  one  and  one-half  pages  will  suffice  to  cover  the 
articulations  of  the  occiput,  the  most  important  of  the  body.  Since  the 
science  of  osteopathy  has  brought  to  the  attention  of  more  than  one  thinking 
orthopedist  the  function  of  the  sacro-iliac  joint,  it  is  safe  to  predict  that  in  less 
than  a  decade  orthopedists  will  have  observed  more  closely  occipital  and 
cervical  lesions  and  in  consequence  there  may  be  found  comprehensive  descrip- 
tions of  all  the  articulations  in  every  text-book  that  treats  of  human  syndes- 
mology. 

Bibliography:     Cunningham,  ibid.,  p.  309-311. 

Deaver,  ibid.,  Vol.  I.,  p.  417-424. 

Gray,  ibid.,  p.  273-278. 

Morris,  ibid.,  p.  218-224. 

Jour,  of  the  A.  O.  A.,  Dec./ 1908,  p.  168;  Jan.  1909,  p.  210;  April, 
1909,  p.  344. 


OSTEOPATHIC  MECHANICS 


189 


FIG.  75 — Drawing  to  represent  by  heavy  dotted  lines  the  position  of  the  occipital  condyles 
in  slight  flexion  of  the  occiput. 

The  amount  of  movement  in  extreme  occipito-atlantal  flexion 
has  been  variously  estimated  and  scarcely  two  observers  are  agreed 
upon  the  amount  of  gliding  that  takes  place.  It  seems  reasonable 
to  conclude,  after  close  study  of  the  two  bones  entering  into  the 
articulation  and  with  due  consideration  to  the  number  of  limiting 
ligaments  and  muscles  about  the  joint,  that  a  gliding  of  more  than 
one-quarter  of  an  inch  is  unlikely  if  not  impossible;  the  extent  of 
the  motion  may  be  even  less.  In  some  cases  an  elongated  dens 
would  prevent  greater  flexion,  in  fact  it  is  not  uncommon  for  an 
articulation  to  be  found  between  the  apex  of  the  dens  on  its  forward 
edge  and  the  anterior  rim  of  the  foramen  magnum,  shown  by  the 
presence  of  articular  facets,  small  in  size,  upon  these  bones. 

Immobilization  of  the  articulations  in  flexion  would  result 
in  the  formation  of  a  flexion  lesion,  called  in  osteopathic  terminology 
a  posterior  occiput.1  The  causes  of  such  a  lesion  would  be  in- 
flammation from  infectious  diseases,  toxins,  or  as  a  result  of  strain; 
contraction  leading  to  contracture  of  the  flexor  muscles ;  atony  of 
the  extensor  muscles  following  long  continued  faulty  posture  in 


1.  A  large  number  of  osteopa trusts  still  use  the  term,  anterior  atlas,  to 
designate  this  lesion.  Since  the  upper  of  the  bones  entering  into  a  vertebral 
joint  is  the  movable  one,  the  name  should  be  that  of  the  upper  bone,  and  this 
applies  to  the  occipito-atlantal  articulations  quite  as  much  if  not  more  than  to 
any  other  spinal  joint. 


190  OSTEOPATHIC  MECHANICS 

consequence  of  refractive  errors,  thoracic  kyphosis  with  accentua- 
tion of  the  cervical  curve,  etc. 

EXPERIMENTAL  PALPATION,  O. — The  presence  or  absence  of 
motion  in  the  occipito-atlantal  articulation  may  be  determined  by 
palpation  only.  Let  the  subject,  B,  who  has  normal  articulations 
between  the  occiput  and  the  atlas,  sit  upon  a  stool,  with  O  standing 
behind  him.  For  convenience,  three  points  may  be  chosen  from 
which  to  estimate  whether  or  not  movement  is  present  in  the 
articulation  under  consideration.  These  points  are  the  posterior 
border  of  the  ramus  of  the  mandible  at  a  point  adjacent  to  the 
transverse  process  of  the  atlas  which  is  the  second  point  in  the 
process  of  comparison;  the  third  point  is  the  tip  of  the  mastoid 
process  of  the  temporal  bone.  Let  O  place  the  radial  side  of  the 
index  finger  against  the  transverse  process  of  the  atlas  letting  the 
nail  rest  against  the  ramus  anterior  and  the  surface  of  the  finger 
also  rest  against  the  mastoid  process  at  the  tip.  If  the  articula- 
tion is  normal,  0  will  find  that  there  is  some  separation  between 
the  anterior  border  of  the  transverse  process  and  the  ramus  while 
the  tip  of  the  mastoid  lies  just  above  or  slightly  in  front  of  the 
posterior  border  of  the  transverse  process.  For  comparison  of 
the  relation  of  the  tip  of  the  mastoid  to  the  posterior  border  of  the 
transverse  process  of  the  atlas,  separately,  O  may  place  the  palmar 
surface  of  the  thumb  against  these  and  palpate  their  contiguous 
surfaces. 

Now  let  O  place  both  index  fingers  in  position  for  palpating 
to  determine  movement,  and  ask  B  to  flex  the  head  forward  wheie- 
upon  O  may  observe  that  the  distance  between  the  ramus  of  the 
mandible  and  the  anterior  border  of  the  transverse  process  has 
become  narrowed  and  that  the  tip  of  the  mastoid  has  moved  be- 
hind the  posterior  border  of  the  transverse  process.  B  is  asked  to 
raise  his  head,  whereupon  the  three  points  resume  their  normal 
relations. 

Since  a  flexion  lesion  signifies  immobilization  in  a  position  of 
flexion,  two  signs  of  such  an  occipital  lesion  would  be  approxima- 
tion of  the  ramus  and  transverse  process  and  separation  of  the 
latter  and  the  tip  of  the  mastoid,  the  mastoid  being  posterior. 

EXPERIMENTAL  PALPATION,  P. — Let  B,  the  patient,  be  one 
who  is  assumed  to  have  a  posterior  occipital  lesion.  0  standing 
behind  B  with  fingers  applied  to  his  occipital  area  as  in  the  first 
part  of  the  above  experiment,  notes  that  the  ramus  is  approxi- 
mated to  the  transverse  process  so  that  the  finger  tip  may  not  be 
placed  between  them.  O  asks  B  to  extend  his  head  backward, 
and  notes  no  resulting  change  in  the  relation  of  the  processes. 


OSTEOPATHIC  MECHANICS  191 

He  is  asked  to  flex  his  head  forward  but  with  no  movement  in  the 
articulation  apparent.  From  the  absence  of  motion  O  may  con- 
clude that  lesion  is  present. 

If,  however,  when  B  bends  his  head  backward,  a  separation 
appears  between  the  anterior  border  of  the  transverse  process  and 
the  ramus  an  anomalous  condition  may  be  present. 

The  atlas  is  often  found  to  have  transverse  processes  that  do 
not  conform  to  the  general  rules  of  proportion  for  the  parts  of 
that  bone.  Its  transverse  processes  may  be  exceedingly  small  so 
that  they  cannot  be  palpated  laterally;  they  may  be  very  large 
so  that  they  are  level  upon  their  outer  surfaces  with  the  mastoids 
and  the  lateral  surfaces  of  the  rami;  they  may  be  irregular,  having 
one  large  and  one  small  transverse  process,  or  one  large  and  the 
other  normal,  or  one  small  and  the  other  normal,  or  with  irregular 
borders,  the  anterior  border  upon  one  side  being  large,  upon  the 
opposite  side  small.  The  sign  of  lesion,1  it  must  not  be  forgotten, 
is  restricted  mobility,  hence  the  only  test  of  an  anomalous  bone 
as  a  part  of  an  articulation  is  motion. 

A  bilaterally  posterior  occipital  lesion  is  one  in  which  the 
occipito-atlantal  articulations  are  immobilized  in  the  position  of 
flexion. 

Since  contraction  of  the  flexors  produces  normal  flexion,  when 
lesion  is  present  the  flexors  are  contracted,  the  extensors  stretch- 
ed. Subsequent  changes  in  these  muscles  will  be  shown  in 
thickening  and  shortening  of  the  flexors  and  atrophy  and  thinning 
of  the  extensors.  The  ligaments  anterior  to  the  articulations  of 
the  occiput  and  atlas  and  the  occiput  and  axis  will  be  shortened 
and  thickened,  the  posterior  ligaments  stretched. 

A  head  immobilized  in  flexion  with  one  vertebra  will  not 
remain  in  that  position  long,  but  will  by  the  accentuation  of  the 
cervical  curve  or  by  the  production  of  two  or  more  cervical  lesions 
restore  erectness  to  itself.  Lesions,  whether  by  group  or  singly, 
thus  produced,  are  at  first  compensatory  or  counterbalancing 


1.  There  may  be  a  lesion  of  a  vertebra  having  anomalous  processes  which 
would  of  course  be  confusing  but  in  such  a  case  the  operative  measures  would 
be  in  the  line  of  securing  motion  through  putting  the  articulation  through  a 
full  range  of  movement  followed  by  corrective  movements  for  the  suspected 
lesion,  which,  if  it  fails  of  correction  after  a  reasonable  number  of  trials,  would 
indicate  that  re-examination  should  be  made  and  with  the  possibility  of  an 
anomaly  present,  it  may  be  decided  to  change  the  operative  technique. 


192  OSTEOPATHIC  MECHANICS 

lesions,  but  due  to  the  weight  of  the  head  and  the  strain  of  holding 
it  upright,  contraction  of  muscles  in  unbalance  causes  the  lesions 
to  be  in  effect  the  same  as  primary  ones. 

These  lesions  are  fairly  common,  the  most  common  of  the 
occipital  group  of  lesions.  The  almost  constant  symptom  of  which 
these  patients  complain  is  an  uneasiness  at  the  back  of  the  neck 
close  to  the  occiput  due  unquestionably  to  the  extra  strain  upon 
the  extensor  muscles  that  any  labor  which  is  performed  with  the 
head  in  flexion  would  subject  them  to.  In  patients  who  have 
acute  lesions  or  are  frail  or  sick,  tenderness  about  the  articulations 
is  often  found. 

CORRECTIVE  MOVEMENTS 

THE  PRINCIPLE  OF  CORRECTION  FOR  A  FLEXION  LESION  OF 
THE  OCCIPITO-ATLANTAL  ARTICULATION  IS  EXTENSION. 

GENERAL  RULES. — SINCE  EACH  OCCIPITAL  CONDYLE  HAS 
MOVED  INWARD  AND  DOWNWARD  AS  WELL  AS  BACKWARD,  IT  MUST 
BE  MOVED  IN  CORRECTION  OUTWARD,  FORWARD,  AND  UPWARD; 
THEREFORE  THE  OPERATIVE  PROCEDURE  FOR  THE  ADJUSTMENT  OF 
A  POSTERIOR  OCCIPUT  MUST  BE  GIVEN  TO  ONE  ARTICULATION  AT  A 

TIME. 

Preliminary  treatment  is  almost  a  necessity  in  these  cases  for 
in  the  presence  of  a  number  of  small  contractured  muscles  it  is 
difficult  to  secure  an  adjustment  early  in  the  treatment  of  the 
articulation.  By  putting  the  cervical  region  through  its  normal 
movements,  with  especial  effort  to  separate  the  origin  and  inser- 
tion of  all  muscles  of  length  attached  to  the  occiput,  atlas,  or  axis, 
preparation  is  made  for  localizing  the  operative  work  at  the 
occipito-atlantal  articulation.  An  attempt  should  then  be  made 
to  put  the  joint  through  its  normal  range  of  movement  but  by 
gentle  means,  after  which  the  corrective  work  should  be  given. 

I.  OUTWARD  EXTENSION  MOVEMENT. — Let  B,  the  patient, 
lie  supine  upon  the  table,  with  his  head  projecting  beyond  the  end 
of  the  table.  O  stands  at  his  head  and  \vith  a  pillow  between  his 
abdomen  and  the  top  of  B's  head  places  pressure  against  the  top 
of  his  head  to  hold  it  in  the  plane  with  his  body.  O  places  his 
hands  overlapped  under  B's  head  with  the  thumbs  resting  against 
the  determining  points  for  observation!,  or  at  least  between  the 

1.  For  the  purpose  of  detecting  when  movement  begins;  at  that  time 
is  the  operative  procedure  effective. 


OSTEOPATHIC  MECHANICS 


193 


FIG.  76 — Illustrating  the  position  of  patient  and  physician  at  the  beginning  of  the  head- 
extension  movement  for  correction  of  the  flexion  lesion  of  the  occiput. 

transverse  process  and  the  ramus,  with  very  light  pressure,  not 
sufficient  to  cause  the  patient  the  least  annoyance  and  never  with 
the  idea  of  fixing  the  atlas  or  of  moving  it. 

0  lifts  B's  head  in  slight  extension  by  raising  the  chin  just  a 
little  and  depressing  the  occiput.  He  then  carries  B's  chin  straight 
to  the  right  without  any  rotation  of  his  face.  By  these  two  move- 
ments he  has  directed  the  right  condyle  forward  and  outward.  By 
an  increase  of  pressure  upon  the  top  of  B's  head,  O  lifts  it  in  ex- 
tension which  should  adjust  the  condyle  to  the  factt  if  there  be  no 
extensive  shortening  of  the  anterior  ligaments  or  calcareous  de- 
posit i  about  the  articulation.  Holding  the  extension,  O  carries 
B's  chin  back  to  the  median  line  and,  bending  his  own  knees  slight- 
ly, he  lowers  B's  head  as  a  whole.  The  movement  is  then  repeated 
with  change  of  direction  to  the  left.  Throughout  the  movement 

1.  Crepitus  is  the  sign  of  such  deposit  about  the  articulation.  The 
patient  often  complains  of  grating  sounds  heard  when  the  head  is  moved.  The 
physician  notes  them  in  corrective  movements  given  the  patient. 


194  OSTEOPATHIC  MECHANICS 

there  is  no  rotation  of  the  head  nor  is  there  any  change  of  the  top 
of  the  head  from  the  median  line  of  the  body. 

Several  repetitions  should  be  made  to  each  side.  The  adjust- 
ment is  not  easily  made  nor  is  it  possible  to  hold  the  correction 
obtained  at  any  treatment  unless  with  the  cooperation  of  the 
patient  who  avoids  flexion  of  the  head  as  much  as  possible  between 
treatments  or  counterbalances  it  by  extension  against  resistance 
to  give  strength  to  the  extensor  muscles.  When  the  joints  have 
attained  a  normal  range  of  movement,  adjustment  may  be  said 
to  be  complete. 

The  counterpart  of  this  movement  may  be  given  with  the 
patient  seated  upon  a  stool.  There  are  variations  in  the  positions 
of  the  hands  which  may  suggest  themselves  to  the  physician  as 
more  suitable  to  his  habit. 


EXTENSION   OF  THE   OCCIPUT 

Extension  is  accomplished  in  the  occipito-atlantal  articulation 
by  a  moving  of  the  condyle  forward,  upward,  and  outward  upon 
the  corresponding  facet  of  the  atlas,  explained  in  detail,  thus; 
when  the  top  of  the  head  moves  backward  both  condyles  glide 
forward  and  since  they  diverge  posteriorly,  their  outer  margins 
must  overhang  the  lateral  edges  of  the  facets,  so  that  they  glide 
outward  as  well  as  forward.  Since  the  anterior  extremity  of  each 
facet  is  on  a  higher  level  than  the  posterior  part,  the  condyle 
also  moves  upward.  When  the  joints  come  to  a  position  of  rest 
in  extension,  the  posterior  two-thirds  of  each  condyle  by  the 
inner  half  of  its  surface  rests  upon  the  outer  half  of  the  anterior 
two-thirds  of  each  articular  facet.  They  move  upon  the  transverse 
axis  of  motion  and  the  extent  of  the  movement  is  no  greater  than 
it  is  in  flexion,  although  provision  has  been  made  in  the  posterior 
condylar  fossse  for  the  reception  of  the  posterior  margins  of  the 
articular  facets  in  extension.  The  depth  and  size  of  these  fossse 
indicate  that  the  movement  is  not  large. 

Immobilization  of  the  articulation  in  extension  would  con- 
stitute the  bilateral  anterior  occipital  lesion.  The  causes  of  the 
production  of  this  lesion  are  inflammation,  after  the  manner  of 
the  invasion  of  any  joint,  contraction  of  the  extensor  muscles, 
atony  of  the  flexors,  weakness  resulting  in  postural  defects  such  as 
round  shoulders  making  it  a  necessity  for  the  subject  to  raise  the 


OSTEOPATHIC  MECHANICS  195 

head  back  in  extension  to  look  at  objects  upon  the  horizon.  It  is 
found  in  very  young  children  before  the  development  of  the  normal 
physiological  curves  is  complete;  it  is  often  found  in  an  old  person 
counterbalancing  dorsal  kyphosis. 

EXPERIMENTAL  PALPATION,  Q. — Let  the  subject,  B,  sit  upon 
a  stool,  O  standing  behind  him  with  his  index  fingers  applied  to 
B's  neck  as  in  experimental  palpation,  O.  B  is  asked  to  carry  his 
head  back  in  extension,  whereupon  O  should  note  that  there  is 
marked  separation  between  the  ramus  and  the  anterior  border  of 
the  transverse  process;  that  the  tip  of  the  mastoid  has  moved  for- 
ward until  it  overhangs  the  anterior  border  of  the  transverse  pro- 
cess. Ask  B  to  resume  the  erect  position  of  his  head  and  the 
distance  will  return  to  the  normal  between  the  ramus  and  the 
transverse  process. 

Palpating  the  posterior  borders  of  the  transverse  processes 
in  relation  to  the  mastoid  processes  with  the  palmar  surfaces  of 
the  thumbs,  the  difference  is  easily  detected  between  the  position 
in  extension  and  the  normal  erect  position. 

EXPERIMENTAL  PALPATION,  R.— Let  the  patient,  B,  be  as- 
sumed to  have  an  extension  lesion  of  the  occiput.  Ask  him  to  sit 
as  in  the  preceding  experiment  upon  the  stool,  0  standing  behind 
him  and  palpating  the  ramus  of  the  mandible  and  the  transverse 
process  to  diagnose  the  condition  of  each  occipito-atlantal  articu- 
lation. O  asks  B  to  bend  his  head  forward  in  flexion.  There  is 
no  change  in  the  relations  of  the  ramus,  mastoid,  and  transverse 
process,  the  ramus  and  transverse  process  being  separated,  the 


FIG.  77 — Drawing  to  represent  by  heavy  dotted  lines  the  position  of  the  occipital  con- 
dyles  in  moderate  extension  of  the  occiput. 


196  OSTEOPATHIC  MECHANICS 

transverse  and  mastoid  approximated.  B  is  then  asked  o  extend 
the  head  and  again  no  change  is  detected,  not  even  an  increase  in 
the  signs  of  the  lesion. 

The  diagnosis  of  the  extension  lesion  is  the  presence  of  the 
distinctive  signs  upon  each  side : 

1.  Restricted  motion. 

2.  Separation  of  the  ramus  of  the  mandible  from  the  anterior 
border  of  the  transverse  process  of  the  atlas. 

3.  Approximation  of  the  tip  of  the  mastoid  and  the  anterior 
border  of  the  transverse  process. 

4.  Straightening  of  the  cervical  curve,  an  effort  at  counter- 
balance. 

A  bilateral  anterior  occiput  may  be  defined  as  a  subluxation, 
or  immobilization,  of  the  occipito-atlantal  articulations  in  the 
position  of  extension. 

The  pathological  changes  about  the  joints  are  contracture  of 
the  extensor  muscles,  atony  of  the  flexors,  calcareous  deposit,1 
shortening  of  the  posterior  ligaments,  and  stretching  of  the  anterior 
and  lateral  occipito-atlantal  and  the  apical  dental  ligaments. 
These  lesions  are  very  uncommon  and  set  up  no  definite  train  of 
symptoms  distinguishable  from  those  found  in  other  occipito- 
atlantal  lesions. 

CORRECTIVE  MOVEMENTS 

THE  PRINCIPLE  OF  CORRECTION  FOR  AN  OCCIPITO-ATLANTAL 
EXTENSION  LESION  IS  FLEXION. 

GENERAL  RULES. — SINCE  EACH  OCCIPITAL  CONDYLE  HAS 
MOVED  FORWARD,  UPWARD  AND  OUTWARD  UPON  THE  FACET,  IT 
MUST  BE  MOVED  DOWNWARD,  BACKWARD,  AND  INWARD  IN  CORREC- 
TION. THE  OPERATIVE  PROCEDURE  FOR  ADJUSTMENT  OF  THE 
ANTERIOR  OCCIPUT  MUST  BE  GIVEN  TO  ONE  ARTICULATION  AT  A 

TIME. 

Preliminary  treatment  is  an  essential  part  in  the  correction 
of  any  occipital  lesion,  and  that  which  has  been  described  for  the 
treatment  of  a  posterior  occiput  applies  to  an  anterior,  lateral,  or 
rotated  occiput  as  well. 

1.  See  the  author's  article,  " Osteological  Proofs",  in  the  Jour,  of  the  A.  O. 
A.,  July,  1914. 


OSTEOPATHIC  MECHANICS 


197 


FIG.  78 — Illustrating  the  position  of  patient  and  physician  at  the  beginning  of  the  head- 
flexion  movement  for  the  correction  of  the  extension  lesion  of  the  occiput. 

II.  OUTWARD  FLEXION  MOVEMENT. — 'Let  the  patient.  B,  lie 
supine  upon  the  table  as  in  the  outward  flexion  movement  with  O 
standing  in  the  same  relative  position  to  B. 

O  places  his  abdomen  against  the  pillow  which  he  places  be- 
tween B's  head  and  the  pressure  directed  through  O's  body  to  the 
top  of  B's  head.  O  rises  slightly  upon  his  toes  until  he  has  lifted 
B's  occiput  and  depressed  his  chin  slightly.  He  then  places  the 
heels  of  his  hands  upon  B's  malar  bones  with  the  fingers  directed 
downward,  the  middle  fingers  palpating  the  posterior  borders  and 
adjacent  surfaces  of  the  mastoid  processes,  for  the  purpose  of  de- 
tecting when  correction  has  begun  in  the  articulations. 

O  carries  B's  chin  to  the  left  without  moving  the  top  of  his 
head  from  the  mesial  plane,  or  turning  his  face.  O  then  puts  an 
additional  pressure  downward  through  the  malar  bones  at  the 
same  time  rising  a  little  more  upon  his  toes,  adding  to  the  amount 


198  OSTEOPATHIC  MECHANICS 

of  flexion  already  attempted  in  the  joints  by  position.  The  pres- 
sure and  position  are  held  while  the  chin  is  returned  to  the  median 
line,  whereupon  the  pressure  is  relaxed  through  the  hands,  and  the 
physician  lessens  the  degree  of  rising  upon  his  feet,  until  the  posi- 
tion is  the  same  with  which  the  movement  started.  The  move- 
ment is  then  repeated  in  the  opposite  direction. 

Several  repetitions  should  be  made  to  each  side.  The  palpa- 
ting fingers  will  be  able  to  determine  when  movement  begins  in  the 
joints.  Between  treatments  the  patient  may  assist  by  exercis'.ng 
the  atonic  flexors  by  resistance  exercises. 

Following  adjustment,  the  articulations  should  be  put  through 
their  range  of  movements  again  and  again  until  each  is  known  to 
be  normal.  It  is  then  that  the  lesion  has  been  completely  ad- 
justed. 

SIDEBENDING   OF  THE   OCCIPUT 

Lateral  gliding  of  the  occiput  upon  the  atlas  has  been  described 
in  Morris's  Anatomy,  in  several  editions,  as  a  "sinking  of  the 
lateral  edge  of  one  condyle  a  little  within  the  lateral  edge  of  the 
socket  of  the  atlas"  with  the  "opposite  condyle  projecting  to  a 
corresponding  degree."  The  top  of  "the  head  is  thus  tilted  to 
one  side  and  it  is  even  possible  that  the  weight  of  the  skull  may  be 
borne  almost  entirely  on  one  joint." 

In  sidebending  of  the  top  of  the  head  to  the  right,  the  right 
condyle  glides  downward  and  inward  upon  the  right  articular 
facet  and  the  left  condyle  glides  upward  and  outward  upon  its 
corresponding  facet,  but  the  extent  of  the  movement  is  much  less 
than  takes  place  in  flexion  and  extension,  being  perhaps  not 
greater  than  one-eighth  of  an  inch  in  extreme  lateral  flexion,  its 
movement  limited  by  the  left  alar  and  the  left  anterior  oblique 
ligaments.  Its  axis  of  motion  is  an  antero-posterior  one. 

When  the  occiput  becomes  immobilized  in  the  position  of 
right  sidebending  from  any  of  the  causes  operative  in  producing 
subluxation,  such  as  trauma,  inflammation,  faulty  posture, 
refractive  error,  contracture  and  atony  of  muscles,  the  top  of  the 
head  is  bent  away  from  the  horizontal  plane  and  the  first  effort 
on  the  part  of  the  individual  thus  afflicted  is  to  make  erect  the 
head,  by  producing  a  cervical  curve,  convex  on  the  side  on  which 
the  condyle  has  sunk,  concave  on  the  other  side,  or  by  the  pro- 
duction of  a  secondary  atlas  lesion,  or  when  the  lateral  occipital 


199 


FIG.  79 — Drawing  to  represent  by  heavy  dotted  lines  the  position  of  the  occipital  condyles 
in  left  sidebending  of  the  occiput. 

lesion  is  slight  in  extent  by  a  cervical  lesion,  anterior  to  the  same 
side. 

The  lesion  is  termed  an  occiput  lateral  to  the  left,  named 
from  the  prominence  of  the  mastoid  process  which  in  sidebending 
to  the  right  is  carried  upward  and  outward  upon  the  left. 

EXPERIMENTAL  PALPATION,  S. — Let  the  subject,  B,  sit  upon  a 
stool  behind  which  0  stands,  with  his  index  fingers  palpating  the 
area  of  the  transverse  processes  of  the  atlas  and  the  mastoid  pro- 
cesses of  the  temporals.  He  then  asks  B  to  sidebend  his  head 
to  the  right,  whereupon  O  should  detect  that  the  tip  of  the 
right  mastoid  has  moved  slightly  to  the  left  and  has  approached 
vertically  the  transverse  process  so  that  it  is  not  difficult  for  the 
palpating  finger  to  note  the  difference  between  the  lateral  position 
and  the  normal.  Upon  the  left,  the  tip  of  the  mastoid  projects 
laterally  in  a  noticeable  manner  beyond  the  lateral  edge  of  the 
transverse  process  and  it  is  also  separated  vertically  from  it. 

Immobilization  of  the  occipito-atlantal  articulation  in  the 
position  of  right  sidebending  would  be  the  definition  of  a  left 
lateral  occiput  and  from  the  experimental  palpation  above,  the 
diagnosis  may  be  deduced : 

1.  Restricted  motion. 

2.  Separation  of  the  tip  of  the  right  mastoid  from  the  trans- 
verse process  below  with  lateral  projection  of  the  mastoid. 

3.  Approximation  of  the  tip  of  the  left  mastoid  and  the  trans- 
verse process  with  lack  of  prominence  laterally  of  the  mastoid. 

4.  The  presence  of  counterbalancing  lesions. 


200 


OSTEOPATHIC  MECHANICS 


CORRECTIVE  MOVEMENTS 

THE  PRINCIPLE  OF  CORRECTION  FOR  A  LATERAL  OCCIPITAL 
LESION  IS  SIDEBENDING  TO  THE  SAME  SIDE. 

GENERAL  RULES. — SINCE  THE  LESION  is  PRODUCED  IN  SIDE- 
BENDING  TO  ONE  SIDE,  CORRECTION  MUST  NECESSARILY  BE-  MADE 
BY  SIDEBENDING  TO  THE  OPPOSITE  SIDE  AND  SINCE  EACH  CERVICAL 
ARTICULATION  ON  THE  SIDE  OF  THE  CONCAVITY  MAY  MOVE  BUT 
ONE-SIXTEENTH  OF  AN  INCH,  CORRECTION  WILL  BE  EASILY  LOCALI- 
ZED IN  THE  OCCIPTIO-ATLANTAL  ARTICULATION  BY  EXTREME  SIDE- 
BENDING. 

III.  CoNDYLE-SiNKiNG  MOVEMENT. — Let  the  patient,  B, 
who  is  assumed  to  have  a  left  lateral  occiput  lesion,  lie  supine  upon 
the  table,  with  his  head  projecting  a  few  inches  beyond  the  table 


Fio.  80 — Illustrating  the  position  of  patient  and  physician  at   the  beginning  of  j__the  con- 
dy!e-6inking  movement  for  the  correction  of  the  right  lateral  occipital  lesion. 


OSTEOPATHIC  MECHANICS  201 

and  resting  against  O's  abdomen,  a  pillow  interposed  between. 
0  places  his  left  hand  on  B's  cheek  for  the  purpose  of  moving  the 
head  as  a  whole  to  the  right.  O's  right  hand  is  placed  under  the 
right  side  of  the  head  so  that  it  may  be  said  to  grasp  the  right 
mastoid  process  in  the  operative  movement  and  to  pull  it  upward 
as  in  a  sidebending  movement  to  the  left. 

O  bends  B's  head  to  the  left  not  turning  the  face  in  rotation. 
After  some  preliminary  sidebending  to  each  side  with  pressure 
maintained  throughout  upon  the  top  of  the  head,  O  carries  the 
head  in  extreme  sidebending  and  then  alternately  adds  a  consid- 
erable amount  of  pressure  in  a  straight  line  toward  the  right 
shoulder  and  relaxes  it  until  when  O  is  satisfied  that  B  has  relaxed 
perfectly.  Then  with  increased  pressure  against  the  left  cheek, 
increased  pulling  upward  upon  the  right  side  of  the  head,  O  gives 
a  sudden  forcible  pressure  against  the  top  of  the  head  which  is 
usually  effective  in  adjusting  the  occiput  to  the  atlas.  The  pop- 
ping sound  is  ordinarily  heard  during  this  correction.  0  holds  the 
head  securely  in  his  hands  and  then  carries  it  to  the  mesial  plane 
of  the  body  and  keeping  it  horizontal  with  pressure  against  the 
top  of  the  head  O  alternately  gives  traction  and  adds  pressure  in 
a  straight  line  downward  toward  B's  feet,  after  which  B  is  com- 
manded to  sidebend  the  head  to  the  left  against  resistance  several 
times  in  the  effort  to  secure  enough  contraction  in  the  atonic  lat- 
eral muscles  to  hold  the  correction  gained. 

Practically  the  same  movement  may  be  given  with  the  patient 
sitting  on  a  stool,  O  standing  back  of  B  and  slightly  to  his  right. 
O  places  his  left  forearm  over  B's  head,  his  hand  under  B's  chin. 
B's  right  hand  rests  against  the  right  side  of  the  neck  to  help  to 
localize  the  movement  in  the  occipito-atlantal  articulation.  The 
operative  movement  is  conducted  as  above. 

The  lateral  occiput  is  third  in  frequency  among  occipital 
lesions,  being  more  common  than  the  anterior  occiput  but  less 
frequent  than  the  rotated  occiput.  It  is  somewhat  easily  adjusted. 

The  after-treatment  accorded  this  lesion  is  practically  the 
same  as  that  indicated  for  any  other  occipital  lesion.  If  there  is  a 
cause  that  can  be  removed  aside  from  that  local  to  the  joint, 
removal  is  the  necessary  procedure. 

ROTATION   OF  THE   OCCIPUT 

Due  to  the  obliquity  of  the  planes  of  the  superior  articular 
facets  of  the  atlas,  rotation  of  the  occiput  does  not  take  place  upon 
a  horizontal  plane.  There  are  elements  of  flexion,  extension,  and 


202 


OSTEOPATHIC  MECHANICS 


FIG.  81 — Drawing  to  represent  by  heavy  dotted  lines  the  positions  of  the  occipital  condyles 
in  rotation  to  the  right  of  the  occipito-atlantal  joint. 

sidebending  in  the  movement.  When  the  occiput  is  rotated  to 
the  right,  the  right  condyle  moves  not  only  backward  but  also 
downward  and  inward;  the  left  condyle  moves  not  only  forward  but 
outward  and  upward.  A  horizontal  place  projected  from  the 
crown  of  the  head  would,  by  rotation  of  the  occiput  to  the  right, 
be  tilted  downward  and  backward  on  the  same  side. 

EXPERIMENTAL  PALPATION,  T. — Let  the  subject,  B,  sit  upon  a 
stool  behind  which  O  stands  with  his  hands  placed  for  palpation 
as  in  the  preceding  experiments  of  this  chapter.  B  is  asked  to 
turn  his  face  to  the  right.  O  should  note  that  the  distance  between 
the  ramus  of  the  mandible  and  the  anterior  border  of  the  trans- 
verse process  in  narrowed  upon  the  right,  while  upon  the  left  it  is 
noticeably  widened.  Upon  the  right  the  vertical  distance  be- 
tween the  tip  of  the  mastoid  and  the  lateral  edge  of  the  transverse 
process  is  slightly  less  than  when  the  head  is  held  erect,  while  upon 
the  left  the  distance  between  the  same  two  points  is  somewhat 
greater.  Let  B  return  his  face  to  the  front  and  then  rotate  his 
head  to  the  left,  whereupon  the  reverse  of  the  preceding  observa- 
tions may  be  made. 

Upon  the  presence  of  the  above  distinguishing  signs  may 
diagnosis  of  a  rotated  occiput  be  made  when  in  addition  there  is 
restriction  of  motion  and  the  presence  of  counterbalancing  lesions 
in  the  atlo-axoid  or  other  cervical  articulations. 

A  rotation  lesion  of  the  occipito-atlantal  articulations  may 


OSTEOPATHIC  MECHANICS  203 

be  defined  as  a  subluxation  or  an  immobilization  of  the  occipital 
bone  upon  the  atlas  in  any  part  of  the  movement  of  head-turning. 
The  Lesion  is  named  according  to  the  side  toward  which  the  head 
turns,  occiput  rotated  to  the  right  or  occiput  rotated  to  the  left. 
The  axis  of  motion  is  an  almost  vertical  one  projecting  upward  from 
the  articulation  of  the  dens  with  the  transverse  ligament. 

The  lesion  is  produced  by  muscular  contracture,  as  an  example 
of  which  may  be  mentioned  torticollis;  traumatism  as  by  severe 
twisting  or  concussion;  lack  of  balance  in  the  contraction  of 
opposing  mucsles  when  strain  occurs;  proximity  to  infective 
processes  from  an  extension  of  inflammation,  and  lastly  from  posture 
incident  to  securing  relief  from  defective  hearing,  eyesight,  or  sec- 
ondary to  irritations  in  the  cervical  region. 

CORRECTIVE  MOVEMENTS 

THE  PRINCIPLE  OF  CORRECTION  FOR  A  ROTATED  OCCIPUT  IS 
ROTATION  TO  THE  OPPOSITE  SIDE. 

GENERAL  RULES. — CONTRACTURED  AND  THICKENED  MUSCLES 
AND  LIGAMENTS  MUST  BE  STRETCHED  AND  RELAXED;  ATONIC 
MUSCLES  MUST  BE  GIVEN  TONE.  WHEN  ONE  SIDE  OF  THE  LESION 
IS  MORE  CLOSELY  RESTRICTED  IN  MOTION  THAN  THE  OTHER,  A 
GREATER  AMOUNT  OF  ATTENTION  SHOULD  BE  GIVEN  TO  THAT  SIDE. 

Preliminary  treatment  may  be  given  to  the  cervical  region 
to  secure  relaxation  of  the. long  muscles  reaching  to  the  occiput 
and  adjoining  vertebrae.  An  attempt  should  be  made  to  put  the 
occipital  articulations  through  the  normal  range  of  movement 
possible  to  them;  in  this  way  may  ligamentous  tissues  be  prepared 
for  correction. 

IV.  FACE-TURNING  MOVEMENT. — Let  the  patient,  B,  who 
has  an  occiput  rotated  to  the  right,  lie  supine  upon  the  table  with 
his  head  extending  a  few  inches  beyond  its  end  against  which  O 
places  his  abdomen,  a  pillow  interposed.  O  makes  steady  pres- 
sure against  the  top  of  B's  head  sufficient  to  maintain  the  head  in 
the  median  plane  of  the  body  without  support  and  without  dis- 
comfort to  the  patient. 

O  places  his  left  hand  against  B's  left  malar  bone,  the  fingers 
pointing  down,  the  middle  finger  applied  to  the  adjacent  edges  of 
the  tip  of  the  mastoid  process  and  the  transverse  process  for  the 
purpose  of  palpation  to  detect  movement  when  it  shall  occur. 


204  OSTEOPATHIC  MECHANICS 

The  right  hand  is  placed  beneath  the  occiput,  grasping  it  to  direct 
its  movement  in  correction  of  that  side  of  the  lesion.  The  thumb 
is  placed  upon  the  adjacent  surfaces  of  the  ramus  of  the  mandible 
and  the  transverse  process  to  detect  the  beginning  of  motion  upon 
that  side. 

O  now  adds  slightly  to  the  pressure  on  the  top  of  B's  head 
sufficient  to  lift  the  chin  slightly  and  depress  the  vertex  a  little, 
the  position  one  of  slight  extension.  O  carries  B's  chin  to  the 
right,  turning  the  face  somewhat  in  the  same  direction  to  bring 
the  condyle  into  slight  exaggeration  of  its  immobilized  position 
and  also  to  give  direction  to  the  extension  used  to  carry  the  right 
condyle  forward,  upward,  and  outward  upon  the  underlying  facet. 
Pressure  is  made  against  the  left  side  of  the  face  with  the  left  hand 
while  the  right  hand  adds  slight  lifting  force  to  the  extension.  O 
lifts  the  chin  by  increase  of  pressure  in  that  direction,  and,  as  the 
head  is  brought  up  to  the  limit  of  extension,  the  attempt  at  adjust- 
ment is  made.  Throughout  the  movement  the  top  of  the  head  is 
not  to  be  carried  from  the  median  line. 

If  the  correction  were  effected  upon  the  right  side  the  condyle 
should  move  forward  to  its  normal  position  or  beyond  it  at  the 
moment  extension  is  completed. 

B's  face  is  now  turned  gradually  toward  the  left  and  the  chin 
is  carried  to  the  left,  back  to  the  median  line,  the  extension  being 
held  to  that  point.  Then  the  top  of  B's  head  is  carried  into  flexion 
by  O's  rising  upon  his  toes  while  at  the  same  time  he  depresses  B's 
chin.  The  turning  of  the  face  and  the  carrying  of  the  chin  to  the 
left  continues  until  the  chin  has  reached  the  limit  of  left  lateral 
flexion  and  turning.  Pressure  is  now  directed  downward  upon 
both  malar  bones  but  especially  upon  the  left  in  a  line  directed 
toward  O's  left  knee  which  depresses  B's  chin  strongly.  O  rises 
a  little  more  upon  his  toes  which  carries  the  vertex  higher.  At 
this  moment  the  left  condyle  should  move  backward,  downward, 
and  inward  upon  the  underlying  facet  of  the  atlas.  The  palpating 
finger  will  detect  this  movement  when  it  occurs. 

The  flexion  is  maintained  while  the  chin  is  being  carried  back 
to  the  median  line  and  the  face  turned  to  the  right  until  the  median 
plane  is  reached,  at  which  time  O  sinks  back  upon  his  feet,  at  the 
same  time  lowering  the  top  of  B's  head,  elevating  his  chin,  until 
the  positions  O  and  B  hold  are  the  same  as  those  at  the  beginning 
of  the  corrective  movement.  The  movement  in  its  entirety  should 
be  repeated  from  five  to  ten  times  at  each  treatment. 

If  one  side  has  a  limited  amount  of  movement  and  the  other 
side  is  quite  restricted,  that  half  of  the  movement  which  applies 
to  the  restricted  side  should  be  repeated  several  times.  It  is  often 
a  simple  matter  to  adjust  the  articulation  which  manifests  slight 


OSTEOPATHIC  MECHANICS  205 

mobility.  As  soon  as  it  is  apparent  that  correction  of  one  part  of 
the  double  lesion  has  been  secured,  the  attention  should  be  given 
almost  solely  to  the  articulation  remaining  in  lesion  for  it  would 
be  unnecessary  and  even  mischievous  to  continue  the  movement  as 
a  whole.  If  one  articulation  is  exceedingly  difficult  to  adjust, 
after  a  reasonable  number  of  trials,  the  top  of  the  head  may  be 
moved  from  the  median  plane  of  the  body  and  sidebent  to  the  side 
opposite  the  condyle  which  has  become  immobilized  in  the  posi- 
tion inward  and  backward  upon  the  corresponding  facet;  when  the 
lesion  is  an  upward,  outward,  and  forward  subluxation  of  the 
condyle,  the  case  may  be  helped  by  sidebending  the  head  slightly 
to  the  same  side. 


UNILATERAL  OCCIPITAL  LESIONS 

There  are  four  of  these  lesions  possible,  an  occiput  anterior 
on  the  left  or  on  the  right ;  an  occiput  posterior  on  the  left  or  on 
the  right.  They  are  traumatic  lesions  usually,  and  are  corrected 
by  the  methods  of  adjustment  for  a  rotated  occiput  with  emphasis 
upon  the  part  which  corresponds  to  the  position  the  occiput  has 
become  immobilized  in.  These  lesions  may  be  denned  as  follows: 

An  occiput  unilaterally  posterior  on  the  right  is  a  lesion  in 
which  the  right  occipito-atlantal  articulation  is  immobilized  in 
the  position  of  rotation  to  the  right  upon  a  vertically  oblique 
axis  drawn  through  the  left  articular  facet. 

An  occiput  unilaterally  anterior  on  the  right  is  a  lesion  in 
which  the  right  occipito-atlantal  articulation  is  immobilized  in  the 
position  of  rotation  to  the  left  upon  a  vertically  oblique  axis 
drawn  through  the  left  articular  facet. 

It  sometimes  happens  that  a  patient  who  had  originally  a 
bilaterally  posterior  or  anterior  occipital  lesion  has  correction  made 
of  one  articulation  instead  of  both  entering  into  the  immobiliza- 
tion known  as  the  posterior  occiput  or  the  anterior  occiput.  The 
condition  that  remains  is  an  unilateral  lesion.  Palpation  of  both 
articulations  through  the  relative  positions  of  the  transverse  process 
with  the  ramus  and  mastoid,  will  establish  the  diagnosis.  A 
considerable  amount  of  deposit  may  be  found  upon  the  side  immo- 
bilized, a  manifestation  of  the  inflammatory  sequences  following 
upon  the  causative  traumatism. 


208  OSTEOPATHIC  MECHANICS 

DIFFERENTIAL  DIAGNOSIS 

Since  restricted  motion  is  the  characteristic  of  every  lesion, 
differential  diagnosis  among  lesions  of  the  same  articulation  must 
be  made  by  the  presence  of  distinctive  signs.  An  anterior  occiput 
is  easily  differentiated  from  a  posterior  occiput  for  in  the  former 
there  is  a  separation  of  the  ramus  from  the  transverse  process  while 
in  the  posterior  occiput  the  ramus  and  transverse  process  are 
approximated.  Both  show  the  same  distances  vertically  con- 
sidered between  the  tip  of  the  mastoid  and  the  lateral  edge  of  the 
transverse  process  while  the  characteristic  sign  of  the  lateral  occiput 
is  that  the  tip  of  one  mastoid  is  approximated  vertically  and  almost 
in  the  same  vertical  plane  with  the  lateral  border  of  the  transverse 
process  while  the  tip  of  the  other  mastoid  process  is  separated  in 
a  vertical  line  from  the  transverse  process  and  it  projects  beyond 
a  plane  erected  vertically  from  the  lateral  border  of  the  transverse 
process.  Both  mastoids  are,  however,  equidistant  from  the  rami 
of  the  mandible,  a  sign  which  differentiates  the  lateral  occiput 
from  some  cases  of  a  rotated  occipital  lesion. 

The  styloid  process  is  sometimes  mistaken  for  the  transverse 
process  when  the  patient  has  exceedingly  small  transverse  processes. 
Careful  palpation  for  the  size  and  shape  of  the  process  should  help 
to  differentiate  it  from  the  transverse. 

Paramastoid  processes1  are  comparatively  uncommon  but 
when  they  are  present  upon  both  sides  the  diagnosis  has  often 
been  mistaken  for  an  ankylosed  occipito-atlantal  case.  They  may 
occur  upon  one  side  only;  they  are  always  placed  posterior  to  the 
true  mastoid  processes  and  spring  from  the  jugular  processes  of 
the  occipital  bone. 

IN  CONCLUSION 

Treatment  of  occipital  lesions  must  be  carefully  administered. 
The  error  of  students  and  physicians  is  the  use  of  too  much  pressure 


1.  Dwight  Museum  of  Harvard  University  has  at  least  three  skulls  show- 
ing the  paramastoid  processes.  The  entire  osteological  collection  is  valuable 
but  the  present  encumbent  of  the  office  of  curator  is  an  old  man  and  discour- 
teous to  scientific  investigators  from  other  schools  of  practice,  offering  a  sharp 
contrast  to  the  treatment  accorded  the  author  and  other  physicians  by  Wistar 
Institute  in  Philadelphia,  The  Royal  College  of  Physicians  and  Surgeons, 
London,  the  Musee  d'Ecole  de  Medicine,  Paris,  and  other  museums  in  this 
country  and  Europe. 


OSTEOPATHIC  MECHANICS  207 

against  the  top  of  the  head  or  in  movements  through  large  arcs. 
Failure  to  adjust  lesions  of  these  articulations  should  be  followed 
by  a  second  trial  using  just  as  little  force  as  possible.  Rough  treat- 
ment of  cervical  muscles  in  the  nature  of  heavy  massage  must  be 
interdicted,  for  dull,  heavy  aching  is  the  usual  consequence  of 
such  work. 

Re-examination  should  be  made  at  the  beginning  of  each 
professional  visit  so  that  the  possibility  of  over-correction  will  be 
avoided.  Where  faulty  habit  has  been  a  causal  factor  in  the 
formation  of  the  lesion,  then  a  small  amount  of  over-correction  is 
to  be  permitted  but  in  cases  of  lesions  which  may  progress  to 
another  type,  as  for  example  when  a  bilaterally  posterior  occiput 
is  over-corrected  upon  one  side  and  causes  a  rotated  lesion,  over- 
correction  is  almost  malpractice  on  the  part  of  the  physician. 

The  planes  of  the  articulating  surfaces  must  be  kept  contin- 
ually in  mind  in  analyzing  the  modes  of  lesion  production  and 
correction.  It  should  be  unnecessary  to  state  that  the  greatest 
skill  is  requisite  for  the  adjustment  of  occipital  lesions. 

LESIONS   OF  THE  ATLAS 

The  atlanto-axial  articulations  are  the  most  freely  movable  of 
the  vertebral  joints.  The  characteristic  movement  between 
these  two  bones  is  rotation  about  the  dens  of  the  epistropheus  as 
a  pivot  in  a  plane  which  is  nearly  horizontal.  The  arthrodial 
joints  are  formed  between  the  inferior  articular  facets  of  the 
atlas  and  the  superior  articular  facets  of  the  epistropheus.  These 
articular  surfaces  are  covered  with  hyaline  cartilage  which  is 
much  thicker  in  the  centre  than  at  the  circumference,  another 
cause  of  increased  mobility.  It  is  believed  that  in  the  erect  posi- 
tion the  curved  surfaces  of  the  cartilaginous  covering  of  the  facets 
are  in  contact  only  and  that  the  head  is  held  erect  by  the  action  of 
opposed  muscles.1 

Flexion,  extension,  and  sidebending  also  take  place  in  the 
atlanto-axial  joints  but  the  last  is  always  accompanied  by  rotation 
as  a  secondary  movement  just  as  rotation  is  accompanied  by 
sidebending,  due  to  the  inclination  of  the  superior  articular  sur- 

1.  See  Morris,  ibid.,  p.  222,  paragraph  8,  and  p.  224,  paragraph  2. 


208  OSTEOPATHIC  MECHANICS 

faces  of  the  axis,  which  slope  outward  and  backward.  There  is  a 
certain  amount  of  lateral  gliding  in  the  atlanto-dental  articulation, 
so  that  when  the  atlas  rotates  to  the  right,  it  turns  upon  the  dens, 
glides  laterally  and  carries  the  greatest  width  of  the  atlantal 
mass  which  lies  external  to  the  articular  facets,  superior  and  in- 
ferior, to  the  right  downward  and  backward;  on  the  left  carries 
the  corresponding  mass  to  the  right  upward  and  inward,  bringing 
it  closer  to  the  central  articulation  and  thereby  elevating  the  left 
side  of  the  head  and  depressing  the  right  side.  It  is  by  this  means 
that  the  crown  of  the  head  is  brought  to  the  horizontal  after  the 
production  of  a  rotated  occipital  or  lateral  occipital  lesion.  A 
right  lateral  occiput,  produced  in  left  sidebending,  depresses  the 
left  side  of  the  head.  A  right  lateral  or  rotated  atlas  bringing 
the  greatest  amount  of  height  upon  the  left  side  of  the  atlanto- 
axial  articulation  closer  to  central  axis  and  the  median  line,  ele- 
vates the  left  side  of  the  head  and  restores  the  crown  of  the  head 
to  the  horizontal.  Such  a  lesion  of  the  atlas  is  a  counterbalancing 
or  secondary  lesion  having  for  its  purpose  the  restoration  of  erect- 
ness  to  the  head. 

Immobilization  of  the  atlanto-axial  articulations  is  rare  and 
is  subsequent  upon  inflammation  usually  as  the  result  of  trauma- 
tism.  Arthritis  often  invades  these  joints  with  the  same  char- 
acteristic sign  of  the  primary  atlanto-axial  lesion,  restricted  motion. 

The  lesions  of  the  atlas  as  classified  by  the  terminology  com- 
mittee of  the  American  Osteopathic  Association,  are  three,  as  fol- 
lows: 

A  lateral  atlas  is  a  lesion  in  which  the  atlanto-axial  articula- 
tions are  immobilized  in  the  position  of  sidebending-rotation. 

A  rotated  atlas  is  a  lesion  in  which  the  atlanto-axial  articula- 
tions are  immobilized  in  the  position  of  rotation-sidebending. 

An  extension  lesion  of  the  atlas  is  a  lesion  in  which  the  atlanto- 
dental  articulation  is  immobilized  in  the  position  of  extension  or 
upward  gliding  of  the  atlantal  facet  upon  the  dental  facet.  It  is 
an  unusual  lesion,  more  often  secondary  in  character.  Often  in 
cases  of  long-standing  the  dens  of  the  epistropheus  gradually  in- 
creases in  height  with  a  corresponding  elongation  of  its  articular 
facet.  In  this  lesion,  the  inferior  articular  facets  of  the  atlas  glide 
upward  and  forward  upon  the  superior  articular  facets  of  the  axis. 


OSTEOPATHIC  MECHANICS  209 

The  lateral  atlas  lesions  are  named  right  or  left  according  to 
the  side  upon  which  there  is  greater  lateral  prominence  of  the 
transverse  process  of  the  atlas.  The  rotated  atlas  lesions  are 
named  according  to  the  side  upon  which  the  atlantal  articular 
facet  has  rotated  backward. 

EXPERIMENTAL  PALPATION,  U. — Let  the  subject,  B,  who  is 
assumed  to  have  a  lateral  atlas  lesion  upon  the  right,  sit  upon  a 
stool  while  O  stands  behind.  O  places  the  palmar  surfaces  of  his 
index  fingers  against  the  lateral  borders  of  the  transverse  pro- 
cesses of  the  axis  to  compare  them  with  the  overhanging  transverse 
processes  of  the  atlas.  If  a  right  lateral  atlas  lesion  is  present, 
the  transverse  process  of  the  atlas  on  the  right  will  extend  later- 
ally much  beyond  the  same  process  of  the  axis,  and  the  lateral 
border  of  the  left  atlantal  transverse  process  will  be  in  the  same 
vertical  ine  with  the  lateral  border  of  the  left  axial  transverse 
process.  The  patient  is  instructed  to  bend  the  head  to  the  right 
and  to  the  left,  whereupon  no  change  in  the  relative  positions  of 
the  processes  under  palpation  takes  place,  and  the  diagnosis  is 
confirmed. 

The  diagnosis  of  a  right  lateral  atlas  lesion  is  established  by 
the  presence  of  the  following  signs : 

1.  Eestricted  motion. 

2.  Marked  projection  of  the  lateral  border  of  the  right  trans- 
verse process  over  the  corresponding  process  of  the  axis. 

3.  The  approximation  vertically  of  the  lateral  borders  of  the 
left  transverse  processes  of  the  atlas  and  axis. 

4.  The  presence  of  a  counterbalancing  lesion  of  the  occiput. 

THE  PRINCIPLE  OF  CORRECTION  FOR  A  LATERAL  OR  ROTATED 
ATLAS  LESION  IS  SIDEBENDING  TO  THE  SAME  SIDE  AS,  OR  ROTATION 
TO  THE  OPPOSITE  SIDE  FROM,  THE  LESION. 

GENERAL  RULES. — ANY  OPERATIVE  MOVEMENT  WHICH  WILL 
ADJUST  AN  OCCIPUT  LATERAL  TO  THE  RIGHT  WILL  ADJUST  AN  ATLAS 
TO  THE  RIGHT;  ANY  OPERATIVE  MOVEMENT  WHICH  WILL  ADJUST  AN 
OCCIPUT  ROTATED  TO  THE  RIGHT  WILL  ADJUST  AN  ATLAS  ROTATED 
TO  THE  LEFT,  WITH  THE  ADDITION  OF  THE  ESTABLISHMENT  OF  THE 
FIXED  POINT  AGAINST  THE  SIDE  OF  THE  AXIS  TOWARD  WHICH  MOVE- 
MENT IS  MADE,  IN  EACH  LESION. 

When  these  lesions  occur  as  counterbalancing  lesions  to  occip- 
ito-atlantal  lesions,  it  is  always  necessary  to  adjust  the  occipital 
lesion  first;  when  the  atlas  lesion  is  primary,  it  may  be  necessary 


210  OSTEOPATHIC  MECHANICS 

to  follow  its  adjustment  with  correction  of  the  counterbalancing 
occipital  lesion.  There  are  scarcely  any  clinical  reports  extant  of 
these  cases  but  osteological  specimens1,  chief  of  which  may  be 
mentioned  those  at  Wistar  Institute,  confirm  the  few  case  histories 
obtainable. 


1.  The  author  has  had  in  her  possession  during  the  past  year  one  of  the 
most  valuable  of  these  specimens,  belonging  to  the  private  collection  of  Dr. 
Raymond  S.  Ward,  of  New  York  City.  It  is  primarily  a  specimen  of  a  lateral 
occiput  with  a  secondary  lateral  atlas  in  which  secondary  changes  in  the  bone 
formation  have  taken  place.  When  the  science  of  vertebral  osteology  shall 
have  attained  its  proper  place  as  a  branch  of  anthropology,  there  will  not  be 
lacking  osteological  proofs  of  every  osseous  lesion. 


OSTEOPATHIC  MECHANICS  211 


CHAPTER  X. 
CLAVICULAR  AND  OTHER  LESIONS 

The  clavicle  helps  to  form  two  joints,  the  sterno-costo-clavic- 
ular  and  the  acromio-clavicular.  Of  both  of  these  articulations1 
subluxation  may  occur.  The  sterno-costo-clavicular  joint  affords 
the  only  connection  between  the  trunk  and  the  upper  extremity 
and  it  takes  part  therefore  in  all  movements  of  the  shoulder  girdle 
and  arm.  The  meniscus  or  articular  disc  is  the  essential  element 
in  the  articulation,  not  only  separating  the  articulating  surfaces 
of  the  bones,  but  binding  them  together  and  affording  attachment 
to  the  anterior  and  posterior  sternoclavicular  and  interclavicular 
ligaments;  by  its  fixation  the  clavicle  is  held  to  the  sternum  and 
prevented  from  over-riding  the  superior  margin  of  the  manubrium 
when  it  is  elevated  or  depressed  rotating  about  an  antero-posterior 
axis. 

EXPERIMENTAL  PALPATION,  V. — Let  the  subject,  preferably 
a  child  of  ten  to  twelve  years  of  age,  sit  upon  a  stool,  with  shoulders 
bare.  O  stands  behind  the  subject  and  reaching  around  with  his 
left  hand  he  places  the  thumb  internal  to  the  sternal  end  of  the 
clavicle,  the  index  finger  at  its  upper  border  and  the  middle  finger 
at  the  margins  of  the  articulating  surfaces  of  the  clavicle,  sternum, 
and  disc  anteriorly,  to  palpate  for  movement  while  the  shoulder 
girdle  is  raised,  circumducted,  and  depressed.  O  grasps  the  upper 
arm  just  above  the  elbow  and  carries  it  from  in  front  upward,  over, 
and  backward.  Just  as  the  arm  is  started  backward  upon  a  re- 
turn in  the  movement  of  circumduction,  0  notes  that  the  sternal 
end  of  the  clavicle  rotates  upon  its  long  axis,  and  glides  upward, 
so  that  it  is  slightly  higher  than  its  fellow  of  the  opposite  side. 
O  then  lowers  B's  arm  to  the  side  and  notes  that  the  clavicle  re- 
turns to  its  normal  position. 

O  then  raises  B's  arm  backward  and  upward  and  as  the  arm 
approaches  an  elevation  above  the  shoulder,  O  may  note  that  the 
clavicle  rotates  on  its  long  axis  inward,  so  that  its  upper  border  is 
slightly  posterior  to  and  lower  than  the  upper  border  of  the  clavicle 
of  the  other  side. 

The  lesions  of  the  sterno-costo-clavicular  articulations  are 
termed  depressed  or  elevated  clavicles.  They  are  defined : 

1.  See  Marion  E.  Clark,  ibid.,  p.  453,  454.  Deaver,  ibid.,  Vol.  I,  p. 
221-224;  Cunningham,  ibid.,  p.  1444, 1445.  Gray,  ibid,  p.  303. 


212  OSTEOPATHIC  MECHANICS 

A  depressed  clavicle  is  a  lesion  in  which  the  sternal  end  of 
the  clavicle  has  moved  backward  and  downward,  or  it  is  an  im- 
mobilization of  the  sterno-clavicular  articulation  in  the  position 
of  rotation  of  the  clavicle  upon  its  long  axis  wherein  the  front 
border  has  moved  upward. 

An  elevated  clavicle  is  a  lesion  in  which  the  sternal  end  of 
the  clavicle  has  moved  forward  and  upward,  or  it  is  an  immobili- 
zation of  the  sterno-clavicular  articulation  in  the  position  of 
rotation  of  the  clavicle  upon  its  long  axis  wherein  the  front  border 
has  moved  downward. 

These  lesions  are  usually  the  result  of  strain  or  traumatism,  falls 
upon  the  outstretched  arm,  the  shoulder,  or  with  the  arm  grasping 
an  object  to  prevent  falling.  Of  the  symptoms  which  have  been 
relieved  by  correction  of  the  lesions,  according  to  clinical  records, 
the  most  prominent  is  vascular  goitre ;  among  the  others  relieved 
by  correction  of  the  lesions,  according  to  clinical  records,  are 
pharyngeal  and  tonsillar  congestions,  headache,  dyspnoea,  dys- 
phagia,  and  esophagismus. 

CORRECTIVE  MOVEMENTS 

THE  PRINCIPLE  OF  CORRECTION  FOR  A  DEPRESSED  CLAVICLE  IS 
ROTATION  ON  ITS  LONG  AXIS  FORWARD;  FOR  AN  ELEVATED  CLAVICLE, 
ROTATION  BACKWARD  AND  DOWNWARD. 

GENERAL  RULES. — SINCE  THE  SHOULDER  GIRDLE  MOVES  AS 
ONE  BONE,  THE  REPLACEMENT  MUST  BE  EFFECTED  BY  THE  LEVERAGE 
OF  THE  UPPER  EXTREMITY  PRINCIPALLY,  WITH  PRESSURE  AGAINST 
THE  UPPER  BORDER  OF  THE  CLAVICLE  TO  ASSIST  IN  GIVING  THE 
MOVABLE  BONE  A  TURN  IN  THE  RIGHT  DIRECTION. 

I.  FORWARD  AND  UPWARD  MOVEMENT. — Let  the  patient,  B, 
who  has  a  depressed  right  clavicle,  sit  upon  a  stool,  with  O  stand- 
ing behind  him.  O  grasps  B's  right  arm  just  above  the  elbow 
and  carries  it  forward  and  upward  as  high  as  it  will  be  carried 
without  discomfort  to  B,  and  then  backward  slowly  while  at  the 
same  time  with  his  left  thumb  against  the  upper  and  inner  margin 
of  the  sternal  end  of  the  clavicle  O  presses  in  the  effort  to  raise 
the  inner  end  of  the  clavicle  and  rotates  it  outward  and  forward. 
At  a  certain  point  about  midway  between  the  upward  position 
and  the  backward  position  at  the  level  of  the  shoulder,  the  greatest 


OSTEOPATHIC  MECHANICS  213 

amount  of  force  is  brought  to  bear  upon  the  clavicle  to  adjust  its 
lesion. 

O  returns  B's  arm  to  his  side,  and  while  holding  the  inner  end 
of  the  clavicle  in  place,  he  asks  B  to  rotate  his  shoulder  girdle  him- 
self, sometimes  with  resistance  placed  upon  the  upper  surface  of 
the  shoulder. 

Many  of  these  lesions  are  difficult  to  retain  in  adjustment  for 
the  ligaments  of  the  articulation  have  become  so  relaxed  that  it  is 
only  after  repeated  adjustments  that  the  integrity  of  the  joint  is 
secure. 

II.  BACKWARD  AND  UPWARD  MOVEMENT. — Let  the  patient, 
B,  who  has  an  upward  subluxation  of  the  right  sterno-clavicular 
joint,  be  seated  upon  a  stool  as  in  the  last  movement,  with  0  in 
the  same  position,  holding  B's  right  arm  in  the  same  way.  O 
places  the  thumb  of  his  left  hand  in  front  of  the  inner  end  of  B's 
right  clavicle  directing  pressure  against  the  bone  to  assist  in  rota- 
ting it  backward  and  inward  when  0  shall  have  brought  B's  arm  to 
the  position  in  circumduction  backward,  upward,  forward,  and 
downward,  at  which  rotation  of  the  clavicle  along  its  longitudinal 
axis  upward  and  backward  shall  have  been  accomplished.  That 
point  is  commonly  just  before  the  elbow  reaches  the  greatest 
height  above  the  shoulder. 

Lesions  of  the  fifth  and  sixth  cervical  vertebral  articulations 
should  be  adjusted  before  the  clavicular  lesions  may  be  expected 
to  remain  corrected,  for  these  lesions  directly  interfere  with  the 
nerve  supply  to  the  sterno-costo-clavicular  joints. 

The  depressed  lesion  of  the  sterno-clavicular  joint  is  the 
commoner  of  the  two. 

ACROMIO-CLAVICULAR  LESIONS 

The  presence  of  the  acromio-clavicular  joint  is  a  necessity  if 
in  shoulder  movements  the  angle  of  the  scapula  shall  lie  against 
the  thoracic  wall  and  if  the  glenoid  cavity  of  the  scapula  shall 
face  the  same  way  in  every  position,  thereby  putting  upon  the 
movement  of  the  shoulder  joint  no  restrictions.  The  movements 
of  the  acromio-clavicular  joints  are  two,  a  gliding  of  the  clavicle 
upon  the  acromion  anteriorly  and  posteriorly  and  a  rotation  of 
the  acromion  upon  the  clavicle.  Both  movements  are  very  slight 
in  extent  and  difficult  of  palpation  in  any  but  the  youthful  indi- 
vidual who  has  little  adipose  tissue. 


214  OSTEOPATHIC  MECHANICS 

EXPERIMENTAL  PALPATION,  W. — Let  the  subject,  B,  be  seated 
upon  a  stool,  O  standing  behind  him.  O  places  the  palmar  sur- 
faces of  one  or  two  fingers  upon  the  upper  surface  of  the  outer 
extremity  of  the  clavicle  and  the  tip  of  the  acromion  process  of  the 
scapula.  The  eminence  at  the  extremity  of  the  clavicle  will  assist 
in  locating  the  articulation.  0  grasps  B's  right  arm  above  the 
elbow  and  raises  it  directly  to  the  side  until  it  is  on  a  level  with  the 
shoulder-joint.  No  change  in  the  relations  of  the  articulating 
surfaces  of  the  joint  may  be  palpated.  O  then  carries  the  arm 
straight  backward  and  it  may  be  observed  that  the  clavicular 
extremity  glides  forward  upon  the  acromion.  O  then  turns  B's 
arm  in  downward  and  backward  rotation  and  the  clavicular  ex- 
tremity becomes  more  prominent  showing  this  movement  rotates 
the  scapular  articulating  surface  downward  and  forward.  He  then 
returns  the  arm  to  the  side. 

O  then  repeats  the  raising  of  the  arm  and  carries  it  up  and 
over  backward,  which  manifests  at  once  a  rotation  of  the  scapular 
facet  upward  and  backward. 

The  lesions  of  the  acromio-clavicular  articulation  are  those  of 
elevation  and  depression.  They  occur  rarely  but  because  of  the 
distressing  symptoms  following  in  their  train,  they  are  important 
to  understand.  They  are  usually  caused  by  falls.  The  arm  may 
have  been  thrown  above  the  level  of  the  shoulder.  Sometimes  a 
fall  directly  upon  the  shoulder  will  cause  the  lesion. 

Pain  is  the  most  constant  symptom  of  this  lesion  but  because 
of  the  immobilization  of  the  joint,  in  a  position  of  normal  move- 
ment, restricted  movement  characterizes  the  joint.  The  individ- 
ual having  the  lesion  finds  it  impossible  to  put  on  his  coat,  comb  his 
hair,  or  reach  into  a  hip-pocket. 

CORRECTIVE  MOVEMENTS 

THE  PRINCIPLES  OF  CORRECTION  FOR  ACROMIO-CLAVICULAR 
LESIONS  ARE  ROTATION  OF  THE  SHOULDER  UPWARD  AND  BACKWARD 
FOR  AN  ELEVATED  CLAVICLE  AND  ROTATION  UPWARD  AND  FORWARD 
FOR  A  DEPRESSED  CLAVICLE. 

GENERAL  RULES. — IF  THE  LESION  is  ONE  OF  SOME  DURATION, 

IT  IS  OFTEN  NECESSARY  TO  ATTEMPT  MOVEMENT  IN  ALL  DIRECTIONS 
BEFORE  ADJUSTING  THE  LESION.  DlRECT  ADJUSTMENT  IS  NOT 
ALWAYS  POSSIBLE,  THEREFORE,  THE  CLAVICLE  ITSELF  SHOULD  BE 
GUIDED  INTO  PLACE  ACCOMPANIED  BY  ROTATION,  ELEVATION,  AND 
DEPRESSION  OF  THE  SHOULDER  IN  TURN. 


OSTEOPATHIC  MECHANICS  215 

III.  SHOULDER-RAISING    MOVEMENT. — Let    the    patient,  B, 
who  has  a  depressed  lesion  of  the  right  clavicular  extremity,  be 
seated  upon  a  stool,  with  0  standing  behind  him.     0  places  the 
finger  or  thumb  of  his  left  hand  in  front  of  the  outer  third  of  the 
clavicle  with  the  palmar  surface  of  a  finger  palpating  the  articular 
surfaces  of  the  joint.     0  then  grasps  B's  right  arm  at  the  elbow  or 
above,  and  carries  the  arm  at  right  angles  to  the  thorax  laterally 
and  then  rotates  it  upward  and  forward  meanwhile  lifting  by  the 
left  hand  the  clavicle  into  position.     Three  or  four  repetitions  of 
the  movement  may  be  necessary  to  maintain  the  clavicle  in  ad- 
justment. 

IV.  BACKWARD  LIFTING  MOVEMENT. — Let  the  patient,  B, 
who  has  a  backward  and  upward  subluxation  of  the  acromial  end 
of  the  right  clavicle,  sit  upon  the  end  of  the  table,  O  standing  to 
his  right  and  behind  him.     O  places  his  left  hand  over  the  shoul- 
der, the  thumb  under  the  spine  of  the  scapula  to  assist  in  lifting  it, 
the  fingers  upon  the  prominent  extremity  of  the  clavicle  to  assist 
in  guiding  it  back  to  its  accustomed  place  in  the  articulation.     0 
grasps  B's  right  arm  by  the  wrist,  carries  it  backward  in  extension 
rotating  it  inward  at  the  same  time  and  gradually  raising  it  by 
a  vibratory  movement1  until  it  has  been  elevated  to  an  angle  of 
sixty  or  seventy  degrees  with  the  side  of  the  thorax.     Correction 
should  be  effected  toward  the  conclusion  of  the  movement. 

The  above  movement  may  be  varied  by  O's  carrying  B's 
forearm  behind  B's  back  after  it  has  been  raised  about  thirty  de- 
grees from  the  side,  the  left  hand  serving  to  guide  the  extremity  of 
the  clavicle  into  position.  This  movement2  is  used  for  the  adjust- 
ment of  a  clavicle  elevated  at  the  acromial  end. 

PAINFUL  SHOULDERS 

In  connection  with  the  subject  of  lesions  of  the  acromio-clav- 
icular  joint,  a  differential  diagnosis  of  its  chief  symptom,  pain  in 
the  shoulder,  should  be  made  for  the  reason  that  ordinarily  such 
pains  are  classed  as  neuritis,  displaced  biceps  tendon,  rheumatism, 
neuralgia,  and  bursitis.3  By  far  the  larger  number  of  cases  of 
painful  shoulders  are  due  to  bursitis  usually  of  the  subacromial 
bursa.  The  cause  may  be  quite  the  same  as  would  produce  a 
subluxation  of  the  acromio-clavicular  joint,  traumatism  by  falls, 
blows,  and  strains.  In  the  acute  stage  the  characteristic  symptoms 

1.  Method  preferred  by  Dr.  John  A.  MacDonald  of  Boston. 

2.  Dr.  Alex.  F.  McWilliams  of  Boston  uses  this  method  by  preference. 

3.  See  "Differential  Diagnosis",  by  Richard  C.  Cabot,  second  edit.,  1912, 
p.  325,  327,  330,  331,  338. 


216  OSTEOPATHIC  MECHANICS 

are  pain  about  the  joint,  sensitiveness  to  pressure  just  below  the 
acromial  process  and  over  the  bicipital  groove,  when  the  arm  hangs 
at  the  side.  When  the  arm  is  abducted  and  rotated  externally, 
limitation  of  motion  is  discovered  on  account  of  the  extreme  pain 
that  results  from  compression  of  the  bursa  in  these  movements. 
At  night  the  pain  is  worse.  Relief  is  obtained  by  rest,  anodyne 
applications,  and  elevation  of  the  shoulder,  as  when  the  patient 
sits  upon  a  stool  in  front  of  the  physician,  and  the  latter,  resting 
his  foot  upon  the  stool  beside  the  patient,  places  his  knee  in  the 
axilla  and  thus  elevates  the  shoulder.  Grasping  the  arm  near  the 
elbow,  with  some  slight  traction  downward,  it  may  be  stretched, 
which  often  assists  in  giving  relief.  The  chronic  form  of  bursitis 
may  need  surgical  interference.1 

There  is  a  class  of  cases2  which  from  slight  injury,  exposure 
to  cold,  or  over-use  with  fatigue,  manifest  considerable  pain  and 
inconvenience  not  especially  increased  upon  action.  Careful  exam- 
ination should  be  made  to  exclude  all  the  diseases  which  exhibit 
pain  in  the  same  region,  as  osteomyelitis,  malignancy  of  bone, 
joint  fringes,  synovitis,  acute  infectious  polyarthritis,  and  angina 
pectoris.  Osteopathic  examination  will  exclude  subluxations  of 
the  clavicle  at  either  end,  of  the  first  rib,  of  cervical  or  thorac;c 
vertebrae.  Contractions  of  the  muscles  of  the  shoulder  are  always 
present  and  yet  the  case  does  not  warrant  the  designation  of 
myalgia  for  the  reason  that  use  does  not  greatly  increase  the  pain. 
These  cases  are  amenable  to  osteopathic  treatment  through  a 
restoration  of  circulation  to  the  shoulder. 

The  treatment  for  this  class  of  cases  is  palliative  with  the  idea 
of  putting  the  joint  through  the  range  of  normal  movement  with 
especial  attention  to  relaxation  of  the  surrounding  muscles  by 
separating  their  origins  from  their  insertions.  An  agreeable 
method  is  to  rotate  the  shoulder  affected  and  by  gradual  means 
approach  circumduction. 


1.  See  Ashhurst,  ibid.,  p.  466,  467;  Royal  Whitman,  ibid.,  p.  493-496. 

2.  Dr.  Kendall  L.  Achorn  in  the  "Clinical  Department"  of  the  Jour,  of 
the  A.  O.  A.,  Sept.,  1914  and  April,  1915,  has  gathered  case  reports  with  ex- 
pression of  opinion  from  some  prominent  osteopathists  regarding  the  treat- 
ment of  painful  shoulders;  among  these  may  be  mentioned  Drs.  George  J. 
Helmer,  George  Tull,  Normal  B.  Atty,  and  Ernest  Proctor,  who  have  cited 
cases  in  point  with  the  above. 


OSTEOPATHIC  MECHANICS 


217 


FIG.  82 — Illustrating  a  method  of  taking  hold  of  the  upp3r  arm  and  of  the  acromio-clavi- 
cular  tissues  in  treatment  of  a  painful  shoulder. 

VI.  ARM-CIECUMDUCTING  MOVEMENT. — Ask  the  patient  who 
is 'afflicted  with  a  steady  pain  about  the  shoulder  and  much  con- 
traction of  the  muscular  and  ligamentous  tissues,  to  sit  upon  a 
stool,  O  standing  behind  him.  O  grasps  B's  arm  just  above  the 
elbow  and  beginning  quite  close  to  the  side  of  the  patient  carries 
it  in  rotation  and  circumduction  both  forward  and  backward, 
gradually  increasing  the  amount  of  circumduction,  raising  the 
arm  to  a  constantly  higher  level  but  not  to  the  extent  that  the 
arm  is  strained  or  fatigued.  The  movements  must  be  slowly 


218  OSTEOPATHIC  MECHANICS 

executed  and  gently  given  with  perfect  relaxation  on  the  part  of 
the  patient.  It  may  require  six  or  ten  treatments  to  overcome 
the  condition,  depending  upon  its  severity  and  chronicity. 

Acute  brachial  neuritis  is  a  serious  condition,  demanding 
attention  to  the  underlying  causes  with  treatment  of  the  same, 
especially  to  the  correction  of  cervical  lesions  affecting  the  brachial 
nerve  trunks,  the  upper  thoracic  lesions  affecting  the  vaso-motor 
fibres  supplying  the  area.  Manipulative  treatment  of  the  arm  is 
contraindicated,  save  when  at  the  terminal  ramifications  there  is 
evidence  of  atrophic  conditions  and  then  gentle  measures  locally 
applied  with  the  purpose  of  increasing  circulation  are  prescribed. 

LESIONS   OF  THE   MANDIBLE 

The  temporo-mandibular  articulation  is  a  complex  one,  con- 
sisting virtually  of  two  joints,  an  upper  and  a  lower,  the  former 
being  formed  by  the  meniscus  and  the  anterior  part  of  the  man- 
dibular  fossa  and  adjacent  glenoid  ridge;  the  latter,  by  the  menis- 
cus and  the  condyle  of  the  mandible.  The  movements  of  the 
lower  jaw  are  compound,  that  which  takes  place  in  the  upper  joint 
consisting  of  a  gliding  forward  slightly  of  the  cartilage;  in  the 
lower  joint,  of  a  revolving  of  the  condyle  upon  a  transverse  axis 
upward  and  forward  or  an  alternate  action  of  the  two  condyles, 
wherein  the  one  which  starts  the  movement  not  only  revolves 
forward  but  also  rotates  upon  a  central  vertical  axis  inward; 
upon  its  regression,  the  other  advances;  the  movement  of  both 
schematically  outlined  would  be  represented  by  a  figure  8  hori- 
zontally drawn.  It  has  been  called  an  oblique  rotatory  action. 

EXPERIMENTAL  PALPATION,  X. — Let  the  subject,  B,  sit  near 
the  end  of  the  table.  O  stands  in  front  of  him.  B  is  instructed 
to  open  his  mouth  and  then  close  his  teeth  without  closing  the 
lips.  O  notices  whether  or  not  the  front  teeth  of  the  lower  jaw  and 
those  of  the  upper  meet  exactly.  O  then  moves  behind  B  and 
places  his  fingers,  palmar  surfaces  apposed,  against  both  temporo- 
mandibular  areas.  B  is  then  instructed  to  open  and  close  his 
mouth.  O  may  palpate  the  condyle  as  it  moves  forward  and 
back.  B  is  then  given  something  to  grind  with  his  teeth  and  O 
observes  the  triturating  movement,  or  alternate  advance,  rotation, 

1.  See  Cunningham,  ibid.,  p.  313;  Gray,  ibid.,  p.  279-281,  380;  Frazer, 
ibid.,  p.  247,  250;  Ashhurst,  ibid.,  p.  392;  Morris,  ibid.,  p.  215-218,  342. 


OSTEOPATHIC  MECHANICS  219 

and  return  of  each  condyle.     If  the  articulations  are  normal,  no 
difference  will  be  palpated  between  the  two  sides  in  each  movement. 

If  B's  teeth  do  not  meet  anteriorly,  the  lower  ones  showing 
that  the  mandible  swerves  to  the  right,  when  O  palpates  laterally, 
he  will  usually  find  that,  upon  the  side  away  from  which  the  jaw 
turns,  the  condyle,  in  depression  of  the  jaw,  moves  more  quickly 
and  farther  forward  than  upon  the  other  side.  Careful  palpation 
through  several  movements  will  reveal  the  fact  that  motion  in  the 
left  articulation  shows  less  limitation  than  in  the  right  articulation. 

The  temporo-mandibular  lesion  is  a  relaxation  lesion  with 
stretched  pterygoid  muscles,  ligaments,  and  usually  with  hyper- 
mobility  of  the  disc.  Its  most  frequent  cause  is  strain  during  the 
movement  of  trituration,  through  an  attempt  to  bite  down  upon  a 
hard  object,  the  joint  upon  the  side  that  is  strained  being  in  action, 
the  other  joint  stationary.  It  may  be  due  to  the  growth  of  a 
wisdom  tooth  unbalanced  by  the  appearance  of  its  fellow  upon 
the  opposite  side.  Frequently,  through  extension  of  an  inflamma- 
tion, such  as  otitis  media,  pharyngitis,  parotitis,  the  joint  may 
become  hypermobile  or  upon  the  opposite  side  contracted  leaving 
the  bulk  of  mastication  for  one  side,  whereupon  muscular  unbal- 
ance results  with  the  sequence  of  a  relaxation  lesion.  When  the 
meniscus  is  very  loosely  apposed  to  the  glenoid  fossa  and  ridge,  a 
clicking  sound  may  be  heard  whenever  the  individual  eats,  a  source 
of  great  annoyance.  Among  the  symptoms  of  which  these  patients 
have  complained,  according  to  clinical  evidence,  are  neuralgia  of 
any  of  the  branches  of  the  trigeminal  nerve,  tic  douloureux,  and 
headache. 

CORRECTIVE  MOVEMENTS 

THE  PRINCIPLE  OF  CORRECTION  FOR  A  LESION  OF  THE  TEMPORO- 
MANDIBULAR  ARTICULATION  IS  RESISTANCE  REPLACEMENT  UPON 
THE  SIDE  IN  RELAXATION  AND  PTERYGOID  AND  LIGAMENTOUS 
STRETCHING  UPON  THE  SIDE  IN  CONTRACTION. 

GENERAL  RULES. — REPLACEMENT  OF  THE  CARTILAGE  AND 
CONDYLE  UPON  THE  RELAXED  SIDE  MUST  BE  SECURED.  BILATERAL 
RESISTANCE  MUST  BE  OFFERED  AGAINST  MANDIBULAR  DEPRESSION, 
PROTRUSION,  AND  RETRACTION. 

III.  CONDYLE  REPLACING  MOVEMENT. — Let  B,  the  patient, 
be  seated  upon  a  stool,  O  standing  behind  him.  If  B  has  a  relaxa- 
tion lesion  of  the  right  temporo-mandibular  articulation,  O  places 
the  palm  of  his  left  hand  against  the  left  side  of  B's  chin,  grasping 


220  OSTEOPATHIC  MECHANICS 

the  chin  so  that  he  may  push  it  to  the  righ  .  He  then  places  the 
palmar  surface  of  his  right  thumb  in  front  of  the  right  condyle  of 
the  mandible.  B  is  asked  to  open  his  mouth,  and  then  to  close  it 
while  O  assists  in  the  replacement  of  the  condyle  by  pressing  against 
it  with  his  thumb  and  pushing  the  mandible  to  the  right  with  the 
left  hand. 

O  then  holds  strongly  against  the  jaw  to  resist  its  swerving 
to  the  left  while  B  opens  and  closes  his  mouth  several  times.  O 
then  places  the  fingers  of  his  left  hand  underneath  the  chin,  the 
heel  of  the  hand  against  the  mental  process.  He  asks  B  to  open 
his  mouth  while  he  resists  the  movement  with  his  fingers,  and  then 
instructs  him  to  close  his  mouth,  while  O  resists  the  closing  with 
the  heel  of  his  hand.  This  movement  is  repeated  several  times 
at  the  conclusion  of  each  treatment. 

The  time  that  is  required  to  correct  a  lesion  of  these  joints 
depends  altogether  upon  the  rapidity  with  which  the  atonic  mus- 
cles and  ligaments  become  normalized. 

LESIONS   OF  THE  HYOID 

The  hyoid  bone  is  suspended  under  the  mandible  by  muscles 
and  ligamentous  elastic  tissues.  It  is  connected  with  the  larynx 
by  four  ligaments  and  the  thyrohyoid  muscle1.  By  irritation 
through  surrounding  and  connecting  tissues,  it  may  be  displaced 
upward  or  downward  with  contractured  and  shortened  supporting 
tissues.  Irritation  is  quickly  manifest  through  the  internal  laryn- 
geal  nerve,  which  pierces  the  thyrohyoid  membrane,  and  by  it  is 
communicated  to  other  branches  of  the  superior  laryngeal  nerve 
and  by  connecting  filaments  to  other  nerves. 

The  commoner  symptoms  arising  from  the  displacement  of 
this  bone  are  coughing,  tickling  in  the  pharynx,  and  a  sensation  of 
constriction  in  the  thyrohyoid  region. 

The  lesion  is  of  the  nature  of  a  muscular  lesion  and  its  adjust- 
ment is  accomplished,  after  careful  diagnosis  to  ascertain  where 
the  principle  contractions  are  located,  by  a  stretching  of  all  con- 
tractions of  ligamentous  and  muscular  tissues,  and  with  replace- 
ment of  the  hyoid  in  position.  Resistance  exercise  may  be  given 
by  asking  the  patient  to  swallow  while  the  physician  holds  the 

1.  See  Gray,  ibid.,  p.  153,  388,  1167-1168,  fig.  985  on  p.  1170,  1175,  1006 
last  paragraph. 

Morris,  ibid.,  p.  501,  fig.  974  on  p.  1212,  figures  980  and  981  on  p.  1216, 
p.  1216,  fig.  985  on  p.  1219. 

Cunningham,  ibid.,  p.  1387,  fig.  855  on  p.  1075. 


OSTEOPATHIC  MECHANICS  221 

hyoid  bone  by  its  cornua.  Vibratory  relaxation,  gently  admin- 
istered, is  often  helpful  in  relaxing  the  thyrohyoid  membrane  and 
the  intrinsic  ligaments  and  muscles  of  the  larynx. 

SPONDYLOLISTHESIS 

One  of  the  rare  lesions  which  has  been  noted  in  medical  litera- 
ture is  a  subluxation  of  the  fifth  lumbar  vertebra,  or  the  fourth  and 
fifth  lumbar  vertebrae,  in  extension  upon  the  sacrum.  The  term 
for  this  lesion  is  spondylolisthesis,  which  means  a  slipping  of  a 
vertebra.  When  the  lesion  occurs  early  in  life,  before  there  has 
been  complete  osseous  development  of  the  parts  of  the  lumbar 
vertebrae,  there  is  exceedingly  great  deformity  in  the  vertebrae 
taking  part  in  this  subluxation,  in  fact  it  may  be  a  congenital 
malformation. 

Acquired  spondylolisthesis  is  the  result  of  overstrain,  injury, 
or  weakness  resulting  in  displacement  from  inability  to  manage 
superincumbent  weight.  In  consequence  of  the  change  in  equi- 
librium, secondary  changes  begin  simultaneously  above  and 
below,  with  a  resultant  posterior  sacral  lesion  and  lessened  pelvic 
inclination;  above,  one  of  two  changes  takes  place,  either  the 
whole  lumbar  spine  goes  forward  in  lordosis  or  the  fourth  lumbar 
vertebra  becomes  lesioned  in  flexion  and  the  spine  above  becomes 
straight.  Diagnosis  is  made  by  palpation  per  rectum  or  vagina. 

The  symptoms  are  those  which  would  naturally  follow  so 
marked  a  disturbance  in  balance,  weakness  and  pain  in  the  back, 
often  radiating  down  the  limbs,  awkward  carriage  and  gait,  lowered 
resistance.  It  occurs  more  often  in  females  than  males.  The 
change  in  the  pelvis  renders  parturition  exceedingly  dangerous 
and  the  Caesarian  section  is  indicated. 

When  there  is  deformity  apparent,  treatment  may  do  little 
or  nothing  in  the  way  of  adjustment  or  correction.  If,  after 
X-radiance  has  shown  the  exact  condition,  there  is  a  chance  to 
change  the  relation  of  the  articulating  surfaces,  the  treatment 
would  be  that  for  any  extension  lesion  coupled  with  treatment 
directed  to  the  overcoming  at  the  same  time  of  all  the  secondary 
lesions,  especially  those  of  the  sacro-iliac  articulations. 

Bibliography:     Royal  Whitman,  ibid.,  p.  142-144. 

"Practical  Obstetrics,"  Grandin,  Jarman,  and  Marx,  1909,  p.  347. 
Bradford  and  Lovett,  3d  edit.,  1907,  p.  385-388. 
"Handbook  of  Obstetrics,"  R.  Cadwallader,  1908,  p.  231-232. 


222  OSTEOPATHIC  MECHANICS 

CHAPTER  XL 
SOFT  TISSUE  TECHNIQUE 

The  osteopathic  physician  recognizes  that  treatment  of  the 
soft  tissues  of  the  body  is  a  necessity  when  a  condition  of  stasis, 
interrupted  nutrition,  mechanical  constriction,  or  malposition 
exists.  Such  treatment  may  be  a  complete  system  in  itself  and 
be  applied  successfully  by  those  who  have  been  specially  trained. 
Sweden  and  Germany  have  had  schools  whose  graduates  were 
admirably  fitted  for  handling  these  cases.  Some  persons  there 
have  been  who  from  ignorance  supposed  that  the  school  of  osteo- 
pathic practice  taught  a  system  not  unlike  that  of  the  foreign 
institutions.  It  should,  however,  be  quite  readily  seen  from  what 
has  gone  before  that  while  the  osteopathic  physician  himself  may 
use  any  or  all  methods  of  increasing  the  tone  of  soft  parts,  of 
removing  detritus,  etc.,  yet  this  represents  by  no  means  the  central 
thought  in  his  treatment.  The  osseous  lesion  is  the  basic  founda- 
tion of  the  mechanics  of  osteopahty. 

The  engineer  may  oil  the  movable  parts  of  his  machine  and 
feed  it  with  fuel  and  water,  but  unless  it  has  been  adjusted,  part 
to  part,  perfectly,  he  knows  that  it  is  illy  equipped  for  any  risks. 
The  human  being  may  be  given  food,  drink,  occupation,  periods 
of  rest,  and  soft  tissue  massage,  but  while  vertebral  subluxations 
remain,  he  is  no  better  fitted  to  travel  the  road  of  life  than  the 
locomotive  with  a  loose  pin  or  worn  nut.  Dr.  Orren  Smith  has  in 
this  connection  offered  an  apt  comparison:  "Manipulation  is  the 
warm  poultice  of  the  nurse;  adjustment  is  the  keen  knife  of  the 
surgeon. " 

Soft  tissue  work  has  certain  well-defined  therapeutic  purposes, 
namely:  stimulation;  inhibition;  equalization,  referring  to  mus- 
cular unbalance;  relaxation;  reflex  activity;  preparation,  in 
anticipation  of  mechanical  replacement  of  subluxated  units ;  pallia- 
tion in  acute  conditions,  and  adjustment  when  used  in  relation 
to  malpositions  or  ptosis.  These  will  now  be  considered  in  greater 
detail. 


OSTEOPATHIC  MECHANICS  223 

Stimulation  and  inhibition  are  terms  which  have  been  used  to 
describe  the  manner  of  manipulating  the  tissues  of  the  body. 
Stimulation  usually  consists  of  a  quick  stroking  or  rotary  mas- 
sage. Inhibition  consists  of  slow,  steady  pressures,  often  applied 
with  stretching  of  the  underlying  or  adjacent  tissues. 

The  term  stimulation  has  reference  to  mechanical  excitation, 
when  used  osteopathically.  It  may  or  may  not  coincide  with  the 
physiological  meaning  of  the  term.  Inhibition,  however,  has 
little  in  accord  with  the  use  of  the  same  word  in  nervous  physiology. 
After  the  publication  of  the  results  of  Sherrington's  experiments, 
especially  those  in  which  he  had  been  assisted  by  Alexander  Forbes, 
the  clinical  evidence  that  had  been  collected  by  the  founder  of 
osteopathy  and  his  early  followers  took  more  definite  form,  and 
certain  well  established  facts  may  now  be  offered  for  laboratory 
proof : 

A.  The  presence  of  definite  centres,  by  which  are  meant  areas 
at  which  stimulation  may  most  speedily  secure  effect  upon  the 
final  common  efferent  neuron. 

B.  The  presence  of  secondary  centres,  points  at  which,  fol- 
lowing fatigue  of  the  synapse  from  stimulation  at  a  primary  centre, 
excitation  will  promptly  bring  a  response  from  an  organ  or  tissue. 

C.  The  production  of  vaso-motor  reactions  which  assist  in 
establishing  immunity,   through  overcoming  the  persistence  of 
conditions  which  invite  infection  and  through  changing  the  specific 
properties  of  the  blood  so  that  antibody  formation  is  hastened  and 
disease  limited. 

These  experiments  also  explain  certain  phenomena  observed 
by  practicians,  as : 

1.  Long  treatments  often  deplete  the  organism,  bring  no  re- 
lief, and  may  be  followed  by  increased  severity  of  symptoms.     The 
explanation  is  that  excessive  stimulation  amounts  to  inhibition, 
since  synapses  have  limited  endurance,  become  fatigued,  and  cease 
to  be  capable  of  conduction. 

2.  Treatment  which  is  not  specifically  directed  to  a  correc- 
tion of  the  existing  condition  but  which  by  way  of  good  measure 
is  applied  to  both  primary  and  secondary  centres  at  the  same  time 
fails  to  have  a  beneficial  effect.     The  cause  of  this  failure  to  secure 


224  OSTEOPATHIC  MECHANICS 

results  is  that  counterstimulation1  of  sufficient  intensity  causes 
the  fields  of  dispersion  to  overlap  and  incoordination  is  the  effect. 
Lack  of  coordination  is  the  product  of  purposeless  excitation. 

3.  The  quick  relief  from  infection  which  is  obtained  in  pa- 
tients who  have  had  osteopathic  treatment,  when  the  acute  condi- 
tion is  handled  without  drugs  and  by  osteopathic  therapeutic 
measures  only,  proves  that  the  more  a  pathway  is  traveled,  the 
less  resistance  it  offers  at  the  synapse.     This  also  demonstrates 
that  manual  mechanics  constitute  what  is  truly  a  natural  process 
for  unlike  the  drug  remedial  agent,2  it  does  avail  in  acute  diseases 
regardless  of  its  previous  use  in  a  tonic  way  or  for  chronic  condi- 
tions. 

4.  A  great  many  patients  receive  almost  instant  relief  from  a 
purposeful,  well-directed  treatment  which  lasts  not  longer  than 
from  three  to  five  minutes.     In  explanation  of  this  it  should  be 
stated  that  a  single  stimulus  by  association  fibres  may  be  relayed 
to  the  whole  cord.     As  an  instance  of  this  may  be  cited  those  cases 
where  adjustment  of  a  spinal  lesion  brings  almost  immediate  and 
perfect  abatement  of  distressing  symptoms.    Cessation  of  excita- 
tion3 may  be  expressed  in  inhibition.     This  may  be  offered  as  the 
foundation  for  Dr.  A.  T.  Still's  oft  repeated  dictum.  "Find  it;  fix 
it;  leave  it  alone. " 

V.  Patients  suffering  from  systemic  diseases  do  not  show  im- 
mediate or  noticeable  response  to  specific  adjustment  or  soft  tissue 
treatment.     The  cause  is  general  and  recovery  is  slowly  made. 
The  cause  lies  in  resistance  at  the  synapse  through  the  presence 
of  toxins  which  result  in  increased  resistance  preventing  stimu- 
lation of  the  final  common  neuron.     Other  causes  operating  in  the 
same  way  are  deficient  local  nutrition  through  interference  with 
the  blood  supply,  its  volume,  its  quality,  and  deficient  elimina- 
tion of  waste  products.     Changes  in  blood  pressure  markedly 
influence  the  condition  of  the  synapse. 

VI.  Some  patients  will  not  respond  to  treatment  administered 
by  certain  physicians.     This  may  be  called  voluntary  inhibition 

1.  Stimulation  applied  simultaneously  to  two  areas. 

2.  The  human  body  acquires  an  immunity  to  drugs,  so  that  even  increased 
or  lethal  doses  show  no  appreciable  effect  upon  the  system. 

3.  As  an  example  of  this  excitation  may  be  given  the  spinal  lesion  which 
acts  as  an  irritant. 


OSTEOPATHIC  MECHANICS  225 

for  the  patient  consciously  or  unconsciously  through  the  basal 
ganglia  or  cortex  increases  the  resistance  at  the  synapse.  The  re- 
active effects  of  cerebral  inhibition  are  less  under  osteopathic 
therapy  than  that  which  employs  drugs,  for  the  drug  acts  as  a 
toxin,  often  of  virulence,  in  such  patients. 

There  is  such  a  wide  difference  in  the  manner  of  administer- 
ing soft  tissue  treatment  that  in  these  pages  the  manner  of  its  per- 
formance can  only  be  suggested.  That  which  is  most  commonly 
employed  is  directed  to  overcoming  muscular  unbalance.  It  is 
done,  after  the  manner  that  has  been  discussed  in  these  pages,  by 
stretching  the  muscles,  whenever  leverage  is  available,  through 
separating  the  origin  and  insertion  of  each  muscle.  By  direct,  so- 
called  inhibitive  pressure,  steadily  and  firmly  applied  over  the 
muscle  mass,  relaxation  of  contractions  may  be  secured,  and  bal- 
ance restored.  By  a  series  of  small  rotary  movements  across  the 
muscle  fibres,  relaxation  may  be  accomplished.  The  manner  of 
doing  these  things  has  followed  no  hard  and  fast  rules  as  with  mas- 
sage and  mechano-therapy  for  the  physician  who  applies  such 
manipulations  understands  perfectly  the  tissue  under  his  fingers 
and  intelligently  applies  whatever  he  thinks  necessary,  taking  into 
consideration  each  case  as  a  separate  entity.  A  preliminary  course 
in  massage  would  avail  a  student  nothing,  in  fact  it  might  be  a 
decided  disadvantage  by  leading  to  routinism  in  treatment.  The 
touch  of  the  physician  should  always  be  used  with  a  diagnostic 
purpose.  If  he  gives  manual  relaxation,  it  should  be  applied  with 
constant  observation,  so  that  physiological  limitations  will  be 
strictly  obeyed. 

The  circulation  to  various  parts  may  be  improved,  either 
through  increasing  anabolism  or  katabolism.  The  treatment  of 
the  liver  is  a  marked  example  of  this.  The  patient  is  placed  in 
one  of  three  positions  for  direct  manipulation  of  the  liver.  When 
he  lies  supine,  with  his  knees  flexed,  the  physician,  standing  at 
his  left,  places  his  left  hand  under  the  angles  of  the  right  seventh 
to  tenth  ribs,  his  right  hand  upon  the  chondral  ends  of  the  same 
ribs  a  little  external  to  their  extremities.  By  simultaneously 
raising  up  with  the  left  hand  and  compressing  with  the  right  hand 
and  then  releasing  the  pressures  quickly,  the  liver  is  given  a  slight 
shock  which  stimulates  the  blood  and  biliary  circulation. 


226  OSTEOPATHIC  MECHANICS 

Another  method,  which  has  been  suggested  by  figure  72, 
page  180,  is  administered  with  the  patient  lying  upon  the  left  side, 
the  physician  standing  behind  the  patient,  who  is  asked  to  reach 
with  his  right  hand  across  the  physician's  back  and  grasp  his  right 
shoulder.  The  ribs  of  the  right  side  are  all  elevated  by  the  physi- 
cian's moving  back  in  extension  upon  the  patient's  right  shoulder. 
The  hands  are  placed  in  the  same  position  as  in  the  movement 
above.  The  patient  may  be  instructed  to  take  a  full  breath  and 
as  he  exhales,  the  physician  bends  over  his  thorax  placing  com- 
pression by  his  chest  against  its  lateral  wall  and  with  his  hands 
compression  anteriorly  and  posteriorly.  A  quick  release  is  made 
following  the  close  of  expiration. 

A  favorite  method  with  many  osteopathists  is  to  treat  the 
liver  with  the  patient  in  the  knee-chest  position  in  practically  the 
same  way  with  additional  lifting  upward  if  there  is  any  visceral 
ptosis  present. 

In  tonsillar  and  pharyngeal  congestions,  drainage  may  be 
promoted  by  relaxation  of  the  tissues  above  the  area  of  the  hyoid 
bone  and  in  the  infra-mandibular  region.  The  movements  given 
are  usually  downward  in  direction. 

The  eye  is  an  organ  helped  often  by  soft  tissue  treatment, 
which  is  administered  by  gentle  tapping  upon  a  finger  resting  over 
the  eye-ball  or  by  slow  and  gentle  compression  of  the  eye-ball. 
A  stroking  of  the  upper  eyelid  from  the  lachrymal  gland  toward 
the  inner  canthus,  if  it  is  done  with  exceedingly  gentle  movement, 
is  soothing  and  palliative  in  conjunctival  inflammations. 

Gynecological  massage  is  a  subject  that  has  been  so  thor- 
oughly covered  by  the  texts  upon  the  subject  that  reference  here 
is  unnecessary  beyond  the  statement  that  it  is  the  treatment  par 
excellence  for  non-surgical  cases. 

In  acute  cases,  due  to  the  wide  variance  in  etiology  and  path- 
ology, it  would  be  futile  to  attempt  a  description  of  the  methods 
employed.  Such  treatment  is  better  discussed  in  a  text  upon 
practice. 

Visceral  ptosis,  when  its  diagnosis  has  been  established,  comes 
especially  within  the  province  of  the  osteopathist,  who  first  of  all 
removes  vertebral  and  costal  lesions,  corrects  postural  defects,  and 
lastly  replaces  viscera  in  their  normal  locations  and  brings  tone 


OSTEOPATHIC  MECHANICS  227 

to  supporting  connective  tissues.1  This  is  not  done  by  a  general 
kneading  of  the  abdominal  contents,  but  by  lifting  the  viscera, 
with  the  patient  in  the  knee-chest  or  Trendelenburg  position. 
The  palmar  surfaces  of  the  fingers  should  be  insinuated  in  among 
the  tissues  until  the  organ  that  shows  the  greatest  deviation  from 
normality  is  found  and  then  lifted  to  its  normal  place  in  the  ab- 
domen. This  applies  particularly  to  the  different  parts  of  the 
colon,  the  stomach,  and  the  kidneys.  The  patient  must  be  taught 
the  value  of  exercise  for  the  abdominal  muscles,  especially  breath- 
ing exercises  of  the  abdominal  type  with  expulsive  exhalations. 
These  exercises  should  be  practiced  before  the  physician  so  that 
there  shall  be  no  misunderstanding  about  the  manner  of  taking 
them.  The  patient  must  also  learn  to  contract  slowly  the  abdom- 
inal muscles  while  lying  supine  or  in  either  of  the  positions  sug- 
gested above.  He  may  even  be  taught  to  massage  his  own  in- 
testines, carefully  raising  them  up  toward  the  thorax,  as  a  daily 
exercise. 

The  manner  of  doing  abdominal  work  must  be  touched  upon. 
Dr.  A.  T.  Still2  has  recently  said,  "Keep  the  points  of  your  fingers 
out  of  all  abdomens  because  if  you  do  not  you  will  bruise  a  kidney, 
an  ureter,  a  spleen,  the  peritoneum,  the  omentum,  or  the  liver,  all 
of  which  are  liable  to  injury  by  rough  handling. "  Again3  he  says, 
"You  must  not  hurt  your  patients  while  you  are  treating  them. 
My  observation  has  been  that  he  who  hurts  his  patient  shows  his 
lack  of  skill." 

Abdominal  treatment  for  the  replacing  of  viscera  and  increas- 
ing the  activity  of  the  liver  is  a  part  of  what  has  been  termed  the 
general  treatment,  whose  expressed  purpose  is  tonic  effect  given 
to  the  entire  system.  This  does  not  mean  to  the  discriminating 
osteopath  soft  tissue  manipulation  of  the  entire  body,  but  rather 
a  spinal  treatment  in  the  nature  of  normal  movements  given  to 
vertebral  articulation,  to  the  occipito-atlantal  joints,  and  to  the 
sacro-iliac  articulations.  The  argument  for  such  a  plan  of  treat- 
ment is  that  since  a  change  of  circulation  is  beneficial  to  all  tis- 


1.  See  Dr.  C.  P.  McConnell's  article  in  the  Jour,  of  the  A.  O.  A.,  June, 
1912,  p. 1159. 

2.  A.  T.  Still,  "Research  and  Practice",  p.  209. 

3.  Same  text,  p.  88. 


228  OSTEOPATHIC  MECHANICS 

sues,  nowhere  in  the  system  would  a  better  circulation  avail  more 
than  about  the  central  nervous  system.  Spinal  movements  are 
those  which  most  quickly  change  the  cordal  circulation.  The 
treatment  of  the  sacro-iliac  articulations  has  for  its  purpose  relief 
from  the  strain  incident  to  the  static  positions  of  the  body  through- 
out the  waking  hours. 

It  is  not  every  patient  who  can  take  a  general  treatment  and 
the  physician  needs  to  exercise  judgment  in  selecting  those  who 
may  with  impunity  receive  what  they  ask  for,  the  general  tonic 
treatment.  It  has  its  danger  for  the  physician,  when  too  often 
repeated,  of  routinism,  which  has  been  the  bane  of  medical  therapy 
since  the  beginning.  The  medical  practitioner  who  always  pre- 
scribes the  same  drugs  for  every  case  that  presents  the  same  symp- 
toms soon  becomes  mired  in  the  ruts  of  habit.  The  perfection  of 
the  art  of  diagnosis  means  nothing  to  him,  improved  methods  of 
therapeutic  practice  pass  him  by  unnoticed  or  at  best  arouse  his 
antagonism.  The  only  danger  which  besets  the  osteopathic  physi- 
cian is  the  alluring  sameness  of  general  treatment,  leading  to  mental 
inertia  and  physical  depletion. 

It  might  be  said,  In  conclusion,  that  osteopathy  stands  for 
increased  tissue  fortification,  chemical  resistance,  high-grade 
bodily  efficiency,  health.  If  it  would  seem  that  too  much  emphasis 
has  herein  been  placed  upon  the  osseous  lesion  and  its  adjustment, 
it  may  be  pointed  out  that  no  other  system  of  medicine  embraces 
this  peculiar  form  of  diagnosis  or  mechanistic  principle  of  cor- 
rection and  while  the  physician  of  the  osteopathic  school  is  counted 
a  skilled  exponent  of  anatomic  adjustment  of  part  to  part,  yet  he 
is  in  every  sense  a  true  physician,  side  by  side  with  physicians  of 
all  other  schools  waging  the  battle  with  disease,  be  it  physical, 
mental,  or  moral.  We  believe  that  when  Andrew  Taylor  Still 
gave  to  the  world  the  principle  that  the  rule  of  the  artery  is  absolute 
he  laid  the  cornerstone  of  the  healing  art  and  that  when  the  super- 
structure of  the  days  to  come  shall  be  reared,  it  will  rest  upon  the 
anatomic  foundation  demonstrated  by  the  constructive  methods  of 
the  science  of  osteopathy. 


OSTEOPATHIC  MECHANICS  229 

ADDENDA 

EXAMINATION  OF  A  PATIENT. — The  student  who  has  completed 
the  study  of  corrective  movements  naturally  asks  the  question, 
"What  is  the  best  approved  method  of  examining  a  patient  to  dis- 
cover his  lesions?"  There  is  a  preferred  method  and  for  the  as- 
sistance of  the  student  it  is  here  offered  in  the  order  that  has  been 
followed  by  the  best  osteopathists : 

PAGES 

Examination  for  functional  curvature 37-39 

Examination  for  scoliosis 55-56 

Experimental  palpation  I,  J,  and  K 128-130 

Examination  of  a  patient 140-142 

The  straight  spine 182 

Experimental  palpation  B 69-70 

Experimental  palpation  D 80 

Experimental  Palpation  E2  and  F 97-98 

Experimental  palpation  A 67-69 

Experimental  palpation  C 80 

Experimental  palpation  E 89 

Experimental  palpation  G 104-105 

Experiment  V 26 

Experimental  palpation  G2  and  H 115-116 

Examination  of  a  patient 164-165 

Diagnosis  of  an  expiration  lesion 168 

Experimental  palpation,  N • 172 

Diagnosis  of  an  inspiration  bucket  handle  lesion 175 

An  expiration  bucket  handle  lesion 176 

Diagnosis  of  llth  and  12th  rib  lesions 178 

Experimental  palpation  O  and  P 190-191 

Experimental  palpation  Q  and  R 195-196 

Experimental  palpation  S 199 

Experimental  palpation  T 202 

Experimental  palpation  U  209 

Experimental  palpation  V 21 1 

Experimental  palpation  W 214 

Experimental  palpation  X 218 

Hyoid  lesions 220 


230 


OSTEOPATHIC  MECHANICS 


INDEX 


Abbott  cast 60-64 

Abbott,  E.  C 60 

Abdominal  treatment 227 

tumors 79 

Acetabulum  of  os  coxse 

136,  137,  146,  152 

Achorn,  Kendall  L 97,  148,  216 

Aching  in  cervical  muscles 207 

Actual  length  of  legs 38 

Acute  diseases 224,  226 

torticollis 117 

Adjustment 222 

After-treatment  for 

anterior  occiput 198 

cervical  lesions 123,  124 

flexion  spinal  lesions 77 

functional  curvature 47 

hyoid  displacement 220 

innominate  lesions.  .  ..149,  155-156 

lateral  occiput 201 

posterior  occiput 194 

rib  lesions 182 

rotated  occiput 201 

rotation  spinal  lesions 95 

scoliosis 63 

sidebending  spinal  lesions  102,  109 
temporo-mandibular  lesions .  .  .  220 

Amenorrhea 151 

Amphiarthrodial  joints 15 

Anabolism 225 

Anemia 59 

Ankles,  weak 99,  140,  151 

Annulus  fibrosus 13 

Anomalous  vertebral  pro- 
cesses   70,  97,  106,  191 

Antagonistic  mus.  action 34,  207 

Anterior 

innominate 150,  151 

occiput 195,  196 

sacrum 132 

spinal  lesion 78,  81 


Anthropology 210 

Antibody  formation 223 

Arch,  flat 40 

Artery,  rule  of 228 

Arthritis 32,  117,  208 

Arthrodia 15,  187,  207 

Association  fibres  relay  stimuli .  .  .  224 
Atlas 

illustration  sup.  surf 187 

lesions  of 189,  198,  207-209 

trans,  proc.  of 191 

Atony  of  muscles 149 

Atrophy  of  discs 80 

Atty,  Norman  B 216 

Auxiliary  signs  of 

innominate  lesions 143 

Auxiliary  treatment 46 

Backache 135 

Balance 16,  225 

Barrel  chest 79 

Biceps  tendon 215 

Bladder  disturbances 71,  135,  151 

Blood  specific  properties 223 

Body  weight,  influence  of 99 

Bone,  plastic 51,  53 

Breathing  exercises 46,  227 

Burner,  Ethel  L 72 

Bursa,  subacromial 216 

Bursitis 215,  216 

Cabot,  Richard  C 143 

Calcareous  deposit  117,  193,  196,  205 

Cardiac  dilatation 59,  186 

Careless  technique 82 

Caries 117 

Carriage  of  the  body, 

awkward 221 

effort  in 17,  149 

Cartilage,  hyaline  articular 207 

Case  history 38,  39,  210 

Celluloid  jacket 62,  63 


OSTEOPATHIC  MECHANICS 


231 


Centres,  osteopathic 

primary 223 

secondary 223 

Cervical 

area Ill 

curvature  of 47,  125 

dissection  of 113 

lesions  of 114,  213 

rib r .  .  .   34 

rotation 26 

vertebra 19,  21,  111 

Children 

frail,  disposed  to  curvature ....   41 

compulsory  exam,  of 34 

Cicatrix,  cause  of  curvature 32 

Circulation 

increased  by  treatment 218 

necessary  to  health 227,  228 

Clavicle,  lesions  of 211,  212 

Clothing,  improper 33 

Colon,  treatment  of 227 

Compound  scoliosis 57 

Congenital 

anomalies 33 

malformations 32 

Congestion 

pharyngeal 226 

tonsillar 226 

Conjunctival  inflammation 226 

Constipation 71,  99 

Cooperation  of  patient 40,  194 

Coordination 224 

Corrective  movements, 

defined 18 

Counterbalance 17 

Counterbalancing  lesions 

89,191,125,208,209 

Count  erstimulation 224 

Creeping  exercise 41,  47 

Crepitus 193 

Curvature 

definition  of 30 

history  of 30 

functional 35 

causes  of .  .  .  .  32-34 


Curvature,  history  of — continued, 
examination  of  patient  .  . .  37-39 
treatment  of 39-47 

structural,  or  scoliosis 30-48 

bone  changes  in 53 

causes  of 48 

compound 57,  58 

deformities  with 55-56 

diagnosis  of 56 

effects  of 58-59 

gymnastics  for 64 

transitional 49 

treatment  of 59-63 

Curve, 

cervical 198 

Curves,  physiological 17 

Cystitis 151 

Deformities 

in  scoliosis 55 

spondylolisthesis 221 

Deposit  calcareous,  117,  193,  196,  205 
Diagnosis 

art  of 228 

of  atlas  lesions 209 

cervical  lesions 117 

extension  lesions 

occipital 196 

spinal 80 

sacral 136 

flexion  lesions 

occipital 190 

spinal 70 

sacral 132 

functional  curvature 39 

innominate  lesions 

anterior 151 

posterior 143 

rib  lesions 
bucket  handle 

expiration 176 

inspiration 175 

expiration 168 

first 171 

inspiration 164 

llth  and  12th 178 


232 


OSTEOPATHIC  MECHANICS 


Diagnosis,  rib  lesions — continued. 

rotation  lesions 90,  105,  202 

sacral  lesions 132,  136 

secondary  lesions 90 

sidebending  lesions  .  .  .  .105,  199 

spondylolisthesis 221 

Diagnostic  ability 117 

Diagnostic  accuracy, 

lack  of 143 

Differential  diagnosis 206,  215 

Diameters  of  the  thorax 135 

Direct  method  of  adjustment ....  72 
Discs 

atrophy  of 80 

intervertebral 12,  14,  20, 

29,  41,  65,88,  103,  104 

sterno-clavicular 211 

temporo-mandibular 218 

Dislocation 32 

Door-jamb 

exercises  against 47 

movements  against 148 

Dorsal 

flexion 21 

kyphosis 79 

Drugs 224,  225,  228 

Dwight  Museum 206 

Dysmenorrhea 151 

Eddy,  George,  dissection  by 113 

Equalization 222 

Equilibrium 16,  221 

Excitation,  mechanism  of 223 

Exaggeration  of  lesion 72 

Examination  of 

curvature  case 37-39 

school  children 35,  51 

Exercises 

breathing 46,  227 

creeping 41,  133 

for  anterior  sacrum 133 

flexion  spinal  lesions 77 

scoliosis 63-64 

Extension 21 

Extension  lesion  of 

group  of  vertebrae 78-79 


Extension  lesion  of — continued. 

innominate 138 

occiput 194 

sacrum 134-136 

vertebra 78-80 

Eye,  treatment  of 226 

Face-turning  in  movement 107 

Farmer,  Frank,  researches  of, 12 

Fatigue 10,  32,  40 

Femur,  leverage  of  ...  .136,  137,  147 

Figure-S  curve 36 

Fixed  point 120 

Flat  back 135 

Flat  foot 140,  151 

Flexibility 20,  63,  64 

Flexible  subject 98,  128 

Flexion 
lesion  of 

innominate 150 

occiput 188,  189 

sacrum 132 

vertebra 65 

localizes  rotation 121 

movement  of 20 

in  dorsal  sidebending 104 

Forbes,  Alexander, 

experiments  of 223 

Forbes,  Harry  Willis.  .117,   119,   124 

Foramina,  intervertebral 65 

Force,  use  of  little 207 

Fracture 32 

Frazer,  Ernest,  anatomist,.  .  .15,  111 

Fryette,  H!  H 116 

Frequency  of  scoliosis 58 

Fulcrum 19 

Function,  loss  of 67 

Functional  curvature 35 

General  treatment 63,  227,  228 

General  upbuilding 40 

Gradual  production  of  lesion  71,  133 
Group  lesions 

extension 86 

flexion 77 

Growth 32 

Gynecologic  massage 226 


OSTEOPATHIC  MECHANICS 


233 


Habit 207,.  228 

Hamstring  muscles,  pull  of 139 

Harvard,  Dwight  Museum  of ...  .206 

Head,  Henry,  law  of 143 

Headache 219 

Heart,  dilatation  of 186 

Heavy  lifting  injurious 96,  99 

Helmer,  George  J 216 

High  side 24,  29,  32,  49 

History  of  case  diagnostic 105 

Hyoid,  lesions  of 220 

contractions  about 226 

Hyperextension 25 

Inclination,  pelvic 126,  221 

Inequality  of  base 37 

Infective  process 32 

Inflammation  of 

conjunctiva 226 

pelvic  viscera 135 

Inhibition 222 

Immobilization 17,  65 

Immunity 223 

to  drugs 224 

Impaction  lesion 10 

Improper  treatment      124 

Incoordination 224 

Injury  producing  lesion 10 

Inlet,  pelvic 127,  131,  134 

Innominate, 

lesions  of 126,  138-149 

points  of  attack 146,  152 

Inspect)On  of  back Hi 

Interosseous  ligament 127 

Intestines,  massage  of 227 

Irritative  influence 10 

Jarring,  effect  of 

sacro-iliac  joints 135 

Jaw,  lesion  of 218 

Jerky  movements 1 18 

Joint 

acromio-clavicular 211-213 

sacro-iliac 127 

sensations  from 101 

spinal 12,  14,  189 

sterno-clavicular  .  .  .  .211-213 


Journal  of  the  A.  O.  A. 

articles  quoted 67,  101,  106, 

124,  148,  178,  196,  216 

Journal  of  Osteopathy 64 

Katabolism 225 

Kidney,  ptosis  of 227 

Knee-chest  position 226-227 

Kyphosis 10,  48,  63,  190 

Landmarks  of  the  spine 18,  19 

Large  patients 93 

Lateral  lesions 

cervical 115 

lumbar 96 

occipital 201,  208 

thoracic 104 

Laughlin,  George  M., 

monograph  of 64 

Length  of  legs ^  .38,  143,  151 

Lesion, 

acute 12 

adjustment  of 18 

chronic 12 

counterbalancing, 

89,  125,  191  208,  209 

denned 9,  10 

emphasis  upon 228 

gradual  production  of 71,  133 

impaction 10 

ligamentous  and  muscular 10 

of  atlas 198,  207 

of  axis  .  .; 117 

of  cervical  vertebra 115 

flexion 67-76 

extension 78-84 

of  dorsal  vertebra 

lateral 102-109 

rotation 87-95 

sidebending 102-109 

of  innominate 

anterior 150 

posterior 138 

of  lumbar  vertebra 

extension 80,  84-86 

flexion  69,  76 

sidebending 96,  102 


234 


OSTEOPATHIC  MECHANICS 


Lesion,  lumbar  vertebra — continued. 

traumatic 97 

of  mandible 218-220 

of  clavicle 

acromio-clavicular  .  .  .  .213,  214 

sterno-clavicular 212,  213 

of  coccyx 157-158 

of  occiput, 

anterior 194 

lateral 198,208 

posterior 191 

rotated 201-205 

unilateral 205 

of  ribs 161 

bucket  handle 174-177 

first 170-174 

2d  to  6th 164-170 

llth  and  12th 177-182 

of  sacrum, 

extension 135 

flexion 132,  221 

of  spondylolisthesis 221 

osseous 10-12 

primary 17 

relaxation 11,  219 

rotation 11 

secondary 17 

sidebending 12 

spinal 11 

traumatic 11-12 

Lever,  principle  of 19 

Localization,  in  movements 82 

Long  levers  faulty 84 

Long  treatments 223 

Loss  of  symmetry 149 

Lost  tone 34 

Lovett,  Robert  W.,  quoted ...  .60,  64 

Lordosis 221 

Lumbago 99 

Lumbar 

flexion 21 

lesions 69,  76,  84-86  96-102 

scoliosis 56 

Lung  capacity 59 


Malformations,  congenital 32 

Malnutrition 10,  32 

Man,  static  position  of 16 

Manipulation 

contraindicated 218 

of  soft  tissues.  ..100,  222,  223,  225 

Mandible,  lesion  of 218-219 

Massage 41,  118,  207,  222,  227 

May,  Lew  A.,  researches  of 135 

McConnell,  Carl  P 12,  67, 

72,  101,  106,  110,  117 

Mechanics 

manual 224 

osteopathic 9 

Mechano-therapy 225 

Meniscus 

sterno-clavicular 211 

temporo-mandibular 218-219 

Metatarsalgia 140 

Morton's  toe 140 

Motion  restricted, 

diagnostic  of  lesions   67,  191,  206 

Moyer,  C.  E.  ,  case  of, 125 

Muscular 

atony 149 

changes  in  scoliosis 54 

insufficiency 71 

lesion 10,  220 

tension 55,  93,  136 

unbalance 219,  222,  225 

Muscles, 

antagonistic  action  of 34 

sensations  from 101 

Myalgia 216 

Myositis 12 

Nervous  disturbances 135 

system 228 

Nervous  physiology 

terms  used  in 223 

Neuritis 215,218 

caused  by  lesions 218 

Neuralgia 215,  219 

Neuron,  final  common 223 

Nucleus  pulposus 14,  112 


OSTEOPATHIC  MECHANICS 


235 


Occiput 
lesions  of 

anterior 194 

differential  diagnosis  of 206 

lateral 198,  208 

posterior 191 

rotated 201-205 

unilateral 205 

Occupations,  influence  of 20,  32 

Orchitis,  caused  by  lesion 140 

Osseous  lesion 11,  12,  222 

Osteological 

collections 156,  206 

proofs 196,  210 

specimen 210 

Osteopathic 

diagnosis 18,  67 

mechanics 9 

physician 40,  122 

principles 9 

technique 18 

Osteopathy,  Founder  of 7,  8, 

126,  224,  227,  228 

Over-correction 61.  157,  207 

Pain 

in  knee 99,  151 

sacral 86 

a  symptom  of  lesion  143,  151,  214 

Paramastoid  processes 206 

Painful  shoulders 215 

Palliation 216,  222 

Palpation 

cervical 114 

course  in, 67 

diagnostic 105-106 

Paralysis,  cause  of 

curvature 34 

Parturition 
affected  by  lesion 135,  221 

Pathology  of  scoliosis 53 

Patient's  spine  bare  for  in- 
spection     66 

Pelvic 

diseases 99 

disturbances 71,  140 


Pelvic — continued . 

floor 135 

inclination 126,  159,  160 

inflammation 135 

inlet 127,  131,  134 

misplacements 151 

outlet 127,  131,  134 

Pelvis, 
false  and  true 127,  131,  134 

Physician 

in  re  confidence 77 

medical 228 

osteopathic 40,  122 

Physiology,  nervous 228 

Physiological  limitations 225 

Planes  of 

articular  surfaces 16,  146,  207 

Points  of  attack 

innominate 146,  152 

Popping  sound 92,  101, 

121,  124,  201 

Posterior  lesion 

innominate 138-149 

occiput 79,  189-191,  207 

sacrum 135 

vertebra 66 

Postural 

curvature 35 

defects 10,  194,  226 

Posture 

defined 17 

faulty 198 

in  lesion  production 189,  203 

in  sleep 33 

Pressure 

effects  in  scoliosis 58 

inhibitive 225 

Preliminary  treatment  of 

anterior  occiput 196 

cervical  lesions 118-119 

curvature 40-41 

innominate  lesions 136 

posterior  occiput 192 

sacral  lesions 133,  136 

scoliosis . .  63 


236 


OSTEOPATHIC  MECHANICS 


Primary  curves 17 

Principles  of  correction 

defined 18 

mechanistic 228 

Prostate  gland 135 

Ptosis 224,226 

Pubic  articulation 141 

Quadruped,  static  position  of,  —  16 
Quain,  Sir  Richard,  anatomist — 126 

Record 

by  adhesive  tape 37 

functional  curvature 39 

Webster 37 

Rectum,  disorders  of 71 

Re-examination  of  patients . .  .46,  207 
Relaxation 

by  corrective  movements 72 

by  posture 43 

lesion 219 

necessary  to  adjustment....!  18,  222 

Remarks  to  patients 77 

Replacement,  path  of 72 

Resistance  movements  for 

cervical  lesions 124 

clavicular  lesions 213 

hyoid  lesion 220 

sidebending  lesion 109 

Response  of  patients 76 

Rest  helpful 77,216 

Restricted  motion 

in  arthritis 208 

sign  of  lesion 67,  191 

Rheumatism 117,  215 

Rib  angularity 55,  183 

Rigidity  of  spinal  column  .  .  .40,  183 
Rotation 

cervical 26 

forcible 25 

lesion 87,  90,  105 

of  areas 15 

of  occiput 201-205 

thoracic 22,  23 

traumatic 11 

Round  shoulders 132,  194 


Routinism 

in  treatment 225,  228 

Sacral  pain 86 

Sacro-sciatic  ligaments 

' 127,  130,  135.  151 

Sacrum,  lesions  of.  .  126,  132-138,  221 

Sayre  head-sling 39 

S-curve 36 

Scapulae,  winged 135 

Schulthess,  statistics  of 58 

Scoliosis 47-64 

changes  in 58 

ligamentous  changes 54 

path,  bone  changes 53 

types  of 48 

School  life  affecting  curvature.  .  .   40 

School  furniture 32 

Secondary  lesions 17,  89,  90,  208 

Secondary  movement 207 

Segments  of  the  spine 46 

Sensations 

from  muscles,  etc 101 

from  areas  of  low  sensibility ...  143 

Sherrington,  experiments  of 223 

Short  treatment 224 

Sidebending  lesions 102,  103 

Sleeping,  habits  of 33 

Smith,  Orren  E 222 

Snapping  of  joints 124 

Soft  tissue  technique 100,  222 

contraindicated 218 

Spontaneous  adjustment 65 

Spondylolisthesis 221 

Standardization  of  technique 19 

Stasis 143,  151 

Steel  tape 20,  131,  138,  141,  151 

Sternum  in  scoliosis 55 

Still,  Andrew  Taylor 7,  8, 

126,224,227,  228 

Stimulation 222 

Stomach,  treatment  of 227 

Straight  spine 182 

Styloid  process 206 

Subluxation  defined 11 

Suspension 17 


OSTEOPATHIC  MECHANICS 


237 


Swedish  massage 222 

Symmetry,  loss  of 149 

Syndesmology 188 

Synapse 223 

Systemic  diseases 224 

Symptoms  resulting  from  lesion 

congestion,  pharyngeal 212 

coughing 220 

constriction  in  throat 220 

dysphagia 212 

dyspnoea 212 

grating  sounds 193 

headache 212 

increase  of 223 

resophagismus 212 

pain 86,  143,  151,  214 

pelvic  disturbances. 71,  99,  135  140 

tenderness 192 

tic  douloureux 219 

tickling  in  throat 220 

uneasiness  in  neck 192 

vascular  goitre 212 

Tape,  steel,  use  of 

20,  131,  138,  141  151 

Tasker,  Dain  L 126 

Technique,  osteopathic 18 

Temporo-mandibular  lesion .  .218-219 
Tenderness,a  symptom.  143,  151,  192 

Tension,  unequal 149 

Therapeutic  diagnosis 106 

Thorax,  scoliotic 58 

Thoracic  vertebrae 12-19 

Thrust  method 72 

Tic  douloureux,  with  lesion 219 

Tone 139,  222 

Torsion 22 

Total  curves 51 

Toxins 10,  224 

Traction  method  . .  .72 


Transverse  processes  of  atlas  191,  206 

Transitional  curvature 49,  51 

Traumatic  lesions  11, 12,  25, 

90,  91,97,  105,  205 

Treatment 

for  curvature 39 

for  scoliosis 63 

rough 41,  207,  227 

Triple  curves 37 

Trituration 218,  219 

Tull,  George 216 

Unbalance 133,  18,  192 

Unilateral  occiput  lesion 205 

Unlocking  of  art.  proc 63 

Varicose  veins 140 

Vaso-motor  reaction 223 

Venous  dilation  59 

Vibration 147,  215,  221 

Visceral 

ptosis 226 

reflexes 10 

Waist-line,  changes  in 56 

Ward,  R.  S 210 

Weakness  in  patient 32 

Webster  record 37,  39 

Wedge-shaped  vertebrae 53 

Weight, 

influence  of 16 

of  head 34 

producing  curvature 40,  48 

superincumbent 221 

Wheel  and  axle  principle 146 

Whole  area  in  lesion 93 

Wisdom  tooth,  cause  of  lesion. . .  219 

Wistar  Institute 206,  210 

Wolff's  law 51 

Wrecked  neck 124 

X-radiance 39,  221 


Date  Due 


n  c  <**  ' 

- 

I-A-M     O 

JAN  2 

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SOUTHERN  REGIONAL  LIBRARY  FACILITY 

405  Hilaard  Avenue,  Los  Angeles,  CA  90024-1388 

Return  this  material  to  the  library 

from  which  it  was  borrowed. 


PRINTED    IN    U.S.' 


UC   IRVINE   LIBRARIES 


3   1970  02064  3075 


A82T  o 
1915 

Ashmcre,  Edythe  F. 
Ost&pathic  mechanics 


MEDICAL  SCIENCES  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 

IRVINE,  CALIFORNIA  92664 


